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Eye-qround   in    Arteriosclerosis 

(After  de  Sehweiniiz) 


^LOOD-PKESSUKE 


ITS  CLINICAL  APPLICATIONS 


BY 
V 
GEORGE  WILLIAM  NORRIS,  A.B.,  M.D. 

ASSISTANT  PROFESSOR  OF  MEDICINE  IN  THE  UNIVERSITY  OF  PENNSYLVANIA)  VISITING  PHYSICIAN 

TO  THE  PENNSYLVANIA  HOSPITAL;   ASSISTANT  VISITING  PHYSICIAN  TO  THE  UNIVERSITY 

hospital;    FELLOW  OF  THE  COLLEGE  OF  PHYSICIANS  OF  PHILADELPHIA; 

MEMBER  OF  THE  ASSOCIATiaN  OF  AMERICAN  PHYSICIANS,  ETC. 


THIRD  EDITION,  THOROUGHLY  REVISED 


ILLUSTRATED  WITH    110   ENGRAVINGS  AND   1    COLORED   PLATE 


LEA   &   FEBIGER 

PHILADELPHIA    AND    NEW    YORK 
1917 


Copyright 

LEA   &    FEBIGER 

1917 


DEDICATED 
TO   THE   MEMORY   OF 

FREDERICK  A.  PACKARD,  M.D. 

WHOSE  MEDICAL  TALENTS  AND  KINDLY  SPIRIT  WERE   UNTIMELY  LOST  TO 

THE   COMMUNITY   OF   PHILADELPHIA,   IN    WHICH   HE   LIVED 

AT  WHOSE  SUGGESTION  AND  UNDER  WHOSE  GUIDANCE 

THE   AUTHOR   FIRST   UNDERTOOK   BLOOD-PRESSURE   INVESTIGATIONS 

AND  TO 

WHOSE   SKILL   AND   SELF-SACRIFICING    PROFESSIONAL    CARE 

HE   IN    A    LARGE   MEASURE   OWES   HIS   LIFE. 


PREFACE  TO  THE  THIRD  EDITION- 


The  exhaustion  of  the  second  edition  of  this  work  within  a  year 
has  given  opportunity  for  the  inclusion  of  a  considerable  amount  of 
new  material.  While  this  has  been  introduced  throughout  the 
book,  particularly  important  additions  have  been  made  in  those 
sections  dealing  with  the  functional  testing  of  cardiac  eflSciency, 
with  blood-pressure  in  disease,  in  the  chapter  on  the  Effects  of  Drugs 
and  in  the  chapter  on  Physiology. 

The  author  has  continued  his  endeavor  to  present  the  subject  of 
blood-pressure  in  a  condensed  and  practical  form  as  definitely  as 
the  present  state  of  our  knowledge  permits.  Whenever  possible  a 
summary  of  the  experimental  as  well  as  the  clinical  data  available 
for  the  consideration  of  a  given  topic  has  been  included,  together 
with  references  to  articles  upon  which  statements  are  based. 

As  in  the  earlier  editions  the  chapters  upon  Physiology  and  upon 
Venous  Blood-pressure  have  been  written  and  revised  by  Dr. 
J.  Harold  Austin.  The  author's  thanks  are  due  to  Miss  Eleanor 
A.  Cantner  for  valuable  assistance  in  the  preparation  of  the  charts 
and  drawings. 

G.  W.  X. 
1530  Locust  Street, 
Philadelphia,  Pa. 


CONTENTS. 


CHAPTER  I. 

The  Physiology  of  Blood-pkessuke 17 

CHAPTER   II. 
The  Instrumental  Estimation  of  Blood-pressure 61 

CHAPTER   III. 

The  Instrumental  Estimation  of  Blood-pressure  (Continued)  .      .       87 

CHAPTER  IV. 
Venous  Blood-pressure 140 

CHAPTER  V. 

The  Functional  Efficiency  of  the  Circulation  as  Determinable 
BY  Blood-pressure  Estimation  and  Allied  Tests 151 

CHAPTER  VI. 
Arterial  Hypotension 193 

CHAPTER  VII. 
Blood-pressure  in  Acute  Infectious  Disease 204 

CHAPTER   VIII. 
Blood-pressure  in  Chronic  Infectious  Disease 222 

CHAPTER  IX. 
Exogenous  Intoxications 232 


viil  CONTENTS 

CHAPTER   X. 
Blood-pressure  in  Cardiac    Disease,  Etc 240 

CHAPTER  XI. 
Blood-pressure  in  Arteriosclerosis — Vascular  Crises    .      .     .     .     258 

CHAPTER  XII. 
Arterial  Hypertensive  Cardiovascular  Disease,  Nephritis,  Etc.    274 

CHAPTER  XIII. 
The  Treatment  of  Arterial  Hypertension 310 

CHAPTER  XIV. 

Effects  of  Drugs  and   Glandular  Extracts  on  Blood-pressure 
(Arranged  Alphabetically) 336 

CHAPTER  XV. 

Metabolic  Diseases  and  Miscellaneous  Conditions 360 

CHAPTER  XVI. 

Diseases  of  the  Nervous  System 386 

CHAPTER  XVII. 
Blood-pressure  in  Surgery  and  Obstetrics 394 

CHAPTER  XVIII. 
Ophthalmology 425 


A  CLINICAL  STUDY  OF  BLOOD-PRESSURE. 


CHAPTER   I. 
THE  PHYSIOLOGY  OF  BLOOD-PRESSURE. 

By  J.  HAROLD  AUSTIN,  M.D. 

Definitions. — Blood-pressure  is  the  term  used  to  indicate  the 
pressure  exerted  by  the  blood  at  a  given  point  in  the  circulatory 
system  at  a  given  moment.  Thus  we  may  speak  of  intra-auricular, 
intraventricular,  arterial,  capillary,  or  venous  blood-pressure.  When 
not  qualified,  the  term  is  used  to  refer  to  the  arterial  blood-pressure, 
and  in  man  usually  to  the  pressure  in  the  brachial  artery.  The 
arterial  blood-pressure  is  constantly  undergoing  rhythmic  fluctua- 
tions due  to  the  cardiac  systoles.  The  highest  pressure  attained 
during  one  cardiac  cycle  is  called  the  systolic  pressure  and  is  attained 
at  the  moment  of  the  arrival  of  the  crest  of  the  pulse  wave.  The 
lowest  pressure  attained  during  a  cardiac  cycle  is  called  the  diastolic 
pressure.  The  difference  between  these  two  pressures  is  called  the 
pulse-pressure.  Thus,  if  the  systolic  pressure  be  120  and  the  diastolic 
90,  then  the  pulse-pressure  would  be  30.  By  mean  pressure  is  under- 
stood the  average  pressure  at  a  given  point.  The  mean  pressure 
is  not,  however,  the  arithmetical  mean  between  the  systolic  and 
diastolic  pressures,  because  the  pressure  may  remain  for  only  a 
moment  at  the  systolic  level,  falling  very  quickly  to  near  the  diastolic 
level  and  remaining  near  it  throughout  the  greater  part  of  the 
average  cycle.  This  is  illustrated  in  Fig.  1,  in  which  obviously 
the  average  pressure  lies  much  nearer  to  the  diastolic  than  to 
the  systolic. 

In  addition  to  the  pressure  oscillations,  dependent  upon  the  cardiac 
cycle  and  called  oscillations  of  the  first  order,  there  are  slower  oscil- 
lations in  the  arterial  pressure  dependent  upon  the  respiratory 
movements.  These  are  called  blood-pressure  oscillations  of  the 
second  order.  Finally,  still  slower  oscillations,  usually  over  ten  to 
twenty  cardiac  cycles,  occur.  These  are  due  to  various  factors, 
2 


18 


PHYSIOLOGY  OF  BLOOD-PRESSURE 


among  which  rhythmic  variations  in  the  activity  of  the  vasocon- 
strictor centre  or  in  the  cardiac  activity  are  the  most  important. 
These  constitute  the  oscillations  of  the  third  order.  All  three  types 
of  oscillations  are  shown  in  the  tracings  (see  Fig.  6). 


M. 


Fig.  1.— ,S 


systolic  pressure;  D  =  diastolic  pressure;  M  =  mean  or 
average  pressxire. 


The  pressure  which  is  exerted  by  the  blood  against  the  vessel 
wall  while  the  current  flows  unobstructed  through  the  vessel  is 
known  as  the  lateral  pressure.  The  pressure  exerted  by  the  blood 
against  an  obstruction  in  the  lumen  of  the  vessel  is  known  as  the 
end  pressure.  The  end  pressure  exceeds  the  lateral  pressure  at  any 
given  point,  and  the  difference  is  the  pressure  that  is  effective  in 
producing  the  blood  flow  at  that  point.  The  accompanying  diagram 
(Fig.  2)  illustrates  the  relation  between  lateral  and  end  pressures. 


Fig.  2. — Illustrating  lateral  pressure:  1,  2,  S,  4,  5,  lateral  pressure  at  points  along 
outflow  tube;  h,  the  diflference  between  lateral  pressiu-e  and  end  pressure  at  any  point. 
(From  Howell.) 


End  pressure  in  a  branch  artery  is  shown  to  be  approximately 
equal  to  the  lateral  pressure  in  the  main  trunk  at  the  point  at 
which  the  branch  takes  origin.  The  method  used  commonly  for 
the  measurement  of  blood-pressure  in  man  shows  the  end  systolic 
pressure  in  the  brachial  artery  and  the  lateral  diastolic  pressure.^ 

'A.  K.  Cushny:    Zentralbl.  f.  Physiol.,  Leipsic  u.  Wien,  1907-8,  xxi,  77;  N.  D. 
Straschesto:   Arch.  f.  d.  ges.  Physiol.,  Bonn,  1909,  cxxviii,  1. 


METHODS  OF  MEASUREMENT 


19 


Blood-pressure  is  usually  expressed  in  millimeters  (sometimes 
centimeters)  of  mercury  above  or  below  the  atmospheric  pressure 
at  the  same  point.  Thus  blood-pressure  of  120  is  a  pressure  that 
will  sustain,  in  addition  to  the  atmospheric  pressure  at  the  point, 
the  pressure  of  a  vertical  column  of  mercury  120  mm.  high. 


Fig.  3. — M,  mercury  manometer;  F,  float;  G,  perforated  cap;  P,  recording  pen; 
C,  cannula  for  insertion  into  vessel;  w,  washout  tube,  shown  in  detail  at  B;  R  and 
E,  for  introduction  and  outflow  of  magnesixim  svdphate  solution;  both  are  clamped 
off  while  recording  pressures.     (From  Howell.) 


Methods  of  Measurement. — ^The  first  exact  measurements  of  blood- 
pressure  were  published  by  the  Rev.  Dr.  Stephen  Hales,  an  English- 
man, in  a  little  book  entitled  Statical  Essays,  in  1733.  He  measured 
the  pressure  in  the  femoral  artery  of  a  horse  by  connecting  it  with 
a  glass  tube  and  noting  the  height  to  which  the  blood  rose  in  this 
tube  held  vertically.  In  1828  Poiseuille  applied  the  mercury 
manometer  to  the  study  of  blood-pressure,  and  in  1847  Ludwig 
invented  the  recording  manometer  with  moving  drum.    Lud wig's 


20  PHYSIOLOGY  OF  BLOOD-PRESSURE 

method  is  essentially  the  one  used  today  in  physiological  experi- 
ments. A  manometer  is  connected  by  tubing  filled  with  some 
fluid  which  will  inhibit  coagulation,  such  as  saturated  magnesium 
sulphate  solution,  with  a  cannula  introduced  into  the  artery.  A 
manometer  so  connected  gives  a  record  of  the  end  pressure  in  the 
artery. 

In  physiological  work-  the  mean  pressure  is  obtained  by  con- 
stricting the  communication  between  the  manometer  and  the  vessel 
to  a  small  opening.  This  prevents  the  transmission  of  the  faster 
blood-pressure  oscillation  to  the  manometer,  and  leads  to  the  pro- 
duction of  a  straight  line  representing  the  average  or  mean  pressure. 
In  studies  upon  man  the  mean  pressure  cannot  thus  be  directly 
recorded  and  is,  in  fact,  difficult  to  determine.  All  pressure  deter- 
mined upon  human  beings  are  therefore,  as  a  rule,  either  systolic  or 


Fig.  4. — Diagram  of  Hiirthle  manometer.  TubinK  from  heart  or  vessel  to  small 
tambour  T,  both  filled  with  fluid.  Movements  of  tambour  magnified  by  compound 
lever  <S,  and  transmitted  to  writing  pen.     (From  Howell.) 

diastolic  pressures.  It  is  the  custom  of  some  authors  to  speak  of 
that  pressure  which  is  half-way  between  the  systolic  and  diastolic 
pressures  in  man  as  the  mean  pressure.  This  seems  to  us  misleading, 
inasmuch  as  it  may  in  certain  cases  be  considerably  above  the  true 
mean  pressure.  Dawson^  has  shown  that  the  mean  'pressure  in 
man  is  usually  obtained  by  adding  approximately  one-third  of  the 
pulse  pressure  to  the  diastolic  pressure.  For  the  measurement  of 
the  systolic  and  diastolic  pressures  in  physiological  work,  Hiirthle 
devised  the  membrane  manometer  which  is  shown  in  Fig.  4,  since 
the  inertia  of  the  column  of  mercury  in  the  mercury  manometer 
is  too  great  to  give  an  accurate  record  of  the  rapid  fluctuations. 
A  manometer  of  still  greater  value  for  the  recording  of  the  more 

1  British  Med.  Jour.,  1906,  ii,  996. 


METHODS  OF  MEASUREMENT 


21 


minute  fluctuations  in  the  blood-pressure  is  that  devised  by  Frank. 
This  consists  of  a  delicate  membrane  manometer  to  which  there  is 
attached,  instead  of  the  lever,  a  small  mirror,  and  the  fluctuations 
of  the  manometer  are  recorded  by  a  beam  of  light  reflected  from  this 
mirror  to  a  moving  film.  Frank  has  also  established  the  mathe- 
matical formulae  by  which  it  is  possible  to  calculate  the  efficiency 


To  the  artery 


Fig.  5. — Maximum-minimum  manometer.  When  cock  a  is  open  and  b  closed,  the 
highest  pressure  attained  diu-ing  the  period  of  record  is  transmitted  to  the  manometer 
and  retained  by  the  maximum  valve.  When  a  is  closed  and  b  opened,  the  mercury 
falls  to  the  lowest  pressure  occurring  in  the  period  of  record  and  is  retained  there  by 
the  minimum  valve. 

of  a  manometer  and  to  distinguish  between  the  waves  which  are 
produced  within  the  manometer  itself,  as  artefacts,  and  those  which 
arise  in  the  vessels  to  which  the  manometer  is  applied.  All  of  the 
more  recent  studies  of  the  minute  variations  in  the  blood-pressure 
have  been  made  by  means  of  a  manometer  based  upon  the  principle 
of  Frank. 


22 


PHYSIOLOGY  OF  BLOOD-PRESSURE 


Another  method  in  use  in  physiological  work  for  the  control  of  the 
membrane  manometer  is  the  so-called  valve  manometer,  or  maximal- 
minimal  manometer.  This  is  illustrated  in  Fig.  5.  By  using  one 
valve  or  the  other,  either  the  highest  or  the  lowest  pressure  occur- 
ring within  a  given  interval  of  time  is  recorded.  The  maximal  press- 
ure recorded  by  such  a  manometer  is  not,  however,  identical  with 


I'liiinii/H  I  It  1 1  III  1 1 11 1 1 1 1  M  i\un  mil  I  1 1 1 1\  I  nni  1 1  n  11 1\  I 


f\(W^ 


Base  Line 


110 


-  80 


40 


-  20  mm 


Jiabbit 


Fig.  6. — Diagram  illustrating  at  Bp  a  typical  blood-pressure  curve  dampened  by 
constricting  the  communication  between  the  artery  and  the  manometer  so  as  to 
reduce  the  amplitude  of  the  shortest  waves.  Shortest  waves,  cardiac;  longer  waves, 
respiratory:  longest  waves  (three  in  the  tracing),  waves  of  third  order.  T,  time 
record  in  seconds,     (From  Howell.) 


the  systolic  pressure,  nor  the  minimal  with  the  diastolic  pressure. 
This  may  be  seen  by  referring  to  Fig.  6.  The  maximal-minimal 
manometer  will  record  the  highest  or  lowest  pressure  attained  over 
a  certain  period  of  time,  and  this  is  usually  long  enough  to  admit 
the  occurrence  of  all  three  orders  of  pressure  oscillations.  It  would 
seem  desirable,  therefore,  to  use  the  terms  maximal  and  minimal 
pressure  in  this  sense.  Certain  authors,  however,  have  used  these 
terms  as  synonymous  with  systolic  and  diastolic  pressures  respec- 
tively. 


BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR   TREE    23 

Measurements  of  the  blood-pressure  in  the  smaller  arterioles 
and  capillaries  either  in  man  or  in  animals  must  be  made  by  other 
methods,  and  are  described  in  a  later  chapter. 

Venous  pressure  is  measured,  in  physiological  work,  in  the  same 
way  as  the  arterial,  but  usually  with  a  water  manometer  rather 
than  with  a  mercury  manometer.  A  pressure  of  34  cm.,  H2O  is 
equal  to  a  pressure  of  25  mm.  Hg.  Blood-pressure  within  the  heart 
is  measured  by  introducing  an  oiled  cannula,  either  through  one  of 
the  vessels  or  through  a  puncture  woimd,  into  the  chamber  within 
which  the  pressure  is  desired. 

BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR  TREE. 

The  blood-pressure  in  an  individual  varies  with  the  point  of  the 
cardiovascular  system  under  consideration,  its  elevation  with 
respect  to  the  heart,  and  with  the  phase  of  the  heart,  whether  systole 
or  diastole.  These  variations  are  indicated  in  the  table  below, 
which  gives  approximate  systolic  and  diastolic  pressures  in  dif- 
fefrent  parts  of  the  cardiovascular  system  at  the  level  of  the  heart 
in  man.  That  the  blood-pressure  varies  greatly  in  different  parts 
of  the  vascular  system  has  long  been  known,  the  marked  differ- 
ence in  the  force  of  the  stream  flowing  from  a  cut  artery  and  from 
a  cut  vein  being  a  striking  illustration. 

Approximate  Pressure  in  Cardiovascular  Tree  of  a  Normal  Man,  Aged 
Twenty  Years,  at  Level  of  Heart. 

In  mm.  Hg. 
Systolic.  Diastolic. 

Left  ventricle 0  to  200 

Aorta 150  to  200                 100  to  120 

Brachial  artery 105  to  140                   80  to  110 

Radial  artery 95  to  125 

Arterioles 80  to    95 

Medium  capillaries 50  to    60                   50  to    60 

Smallest  capillaries 20  to    35                   20  to    35 

Smallest  veins 20  to    30                  20  to    30 

Large  vein  of  arm 1  to    15                     1  to    15 

Right  ventricle 25  to    60 

Pulmonary  artery 25  to    60                   15  to    25 

This  table  is  extremely  diagrammatic  and  is  intended  merely  to 
emphasize  certain  facts.  It  will  be  noted  that  the  chief  fall  in 
pressure  occurs  between  the  smaller  arteries  and  the  capillaries, 
that  is,  in  the  arterioles;  furthermore,  that  this  affects  the  systolic 
pressure  more  than  the  diastolic,  so  that  under  normal  conditions 
the  pressure  in  the  capillaries  shows  no  pulse  wave.  When  the 
arterioles  are  widely  dilated  this  fall  of  pressure,  especially  of  systolic 


24  PHYSIOLOGY  OF  BLOOD-PRESSURE 

pressure,  in  them  is  diminished  and  an  appreciable  pulse  may 
penetrate  into  the  capillaries.  Under  these  conditions  the  systolic 
pressure  in  the  capillaries  approaches  that  in  the  smaller  arteries, 
and  the  diastolic  pressure  in  the  arteries  approaches  that  of  the 
capillaries.  It  will  further  be  noted  that  any  increase  in  venous 
pressure  must  promptly  elevate  the  capillary  pressure.  Indeed, 
the  capillary  pressure  is  more  readily  raised  by  venous  stasis  than 
by  increased  arterial  pressure. 

In  the  recumbent  position  the  lateral  pressure  throughout  the 
entire  length  of  the  aorta  is  very  nearly  constant.  In  the  upright 
position,  however,  the  pressure  at  the  lower  end  of  the  aorta  is 
higher  than  the  pressure  at  the  arch,  by  the  weight  of  the  column  of 
blood  separating  the  two  points;  approximately  2  mm.  Hg.  per  inch. 

Dearborn^  has  recently  studied  in  a  series  of  normal  individuals, 
varying  in  age  from  eleven  to  thirty-two  years,  the  blood-pressure 
in  the  brachial  artery  compared  with  the  pressure  in  the  posterior 
tibial  artery,  the  latter  being  measured  with  the  patient  recumbent 
and  the  leg  either  in  a  horizontal  position  or  in  a  vertical  position 
upward,  and  also  with  the  patient  standing.  The  following  table 
shows  the  range  of  pressures  observed  in  this  series  and  the  averages : 

Posterior  tibial  artery. 
Leg  Leg 

BrachiaL  horizontal.  Standing.         vertically  up. 

Systolic  pressures  .      .    90  to  165         94  to  230         95  to  285         45  to  130 
Average       ....        116.2  138  154.25  70.8 

In  the  veins  the  pressure  is  largely  dependent  upon  posture, 
i.  e.,  upon  the  height  of  the  point  measured  above  or  below  the  right 
auricle.  At  the  right  auricle  the  pressure  is  probably  about  0  to  10 
mm.  Hg.,  varying  with  the  phase  of  respiration,  and  that  in  the  trunk 
is  about  2  mm.  higher  for  every  inch  below  the  heart;  in  the  lower 
extremities,  however,  the  venous  pressure,  while  high,  is  not  so 
high  as  this  calculation  would  indicate  (see  p.  140).  This  relation 
leads  to  some  distention  of  the  veins  in  the  lower  and  dependent 
portions  of  the  body,  while  the  veins  of  the  upper  portion  of  the 
body  are  but  partially  filled. 

The  Factors  that  Maintain  and  Regulate  Blood-pressure.— The 
cardiovascular  system  may  be  considered  from  this  point  of  view 
as  consisting  of  six  elements.  (1)  The  heart,  the  source  of  energy. 
(2)  The  arteries  acting  as  elastic  vessels,  dilating  to  receive  each 
new  ventricular  delivery  of  blood,  and  contracting  to  maintain 

•  Am.  Phys.  Educ.  Rev.,  1915,  xx,  337. 


BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR  TREE    25 

during  the  filling  and  resting  periods  of  the  heart  an  even  flow 
through  the  capillaries.  (3)  The  capillaries,  the  site  of  active 
functionation  of  the  blood  and  with  the  smaller  arterioles  the  chief 
source  of  the  resistance  in  the  circulation.  (4)  The  veins  which 
with  the  capillaries  serve  as  a  reservoir,  maintaining  a  pressure 
just  sufficient  to  fill  promptly  the  relaxing  heart  for  its  next  systolic 
contraction.  (5)  The  blood  itself,  the  incompressible,  inelastic 
medium  which  fills  the  cardiovascular  system.  (6)  The  lymphatic 
system  with  its  tissue  spaces,  serous  cavities,  and  lymphatic  channels 
filled  with  IjTiiph,'  acting  as  an  additional  but  less  promptly  avail- 
able reservoir  for  body  fluids. 

The  Heart. — The  heart  is  the  chief  source  of  the  energy  that 
maintains  the  blood-pressure.  The  factors  that  affect  the  heart's 
efficiency  to  this  end  are  the  factors  that  influence  the  output  of 
blood  per  minute  from  the  heart.  They  are  as  follows:  (1)  The 
diastolic  filling  of  the  ventricles;  this  is  dependent  upon  (a)  the 
venous  pressure,  (6)  the  length  of  diastole,  and  (c)  the  cardiac  tone. 
(2)  The  completeness  of  systolic  emptying.  (3)  The  number  of 
beats  per  minute,  or  cardiac  rate.  (4)  The  efficiency  of  the  valves 
of  the  heart.  The  cardiac  cycle  may  be  divided  into  two  parts: 
(1)  systole,  or  the  period  of  cardiac  contraction;  (2)  diastole,  or 
the  period  of  cardiac  relaxation  and  rest.  The  ventricular  systole 
and  diastole  are  each  further  subdivided.  The  first  one-third  or  one- 
fourth  of  the  ventricular  systole  is  occupied  in  raising  the  pressure 
within  the  ventricle,  from  the  pressure  produced  by  the  auricular 
systole  to  the  diastolic  pressure  of  the  pulmonary  artery  or  of  the 
aorta.  This  is  the  so-called  presphygmic  period  or  "  anspannungs- 
zeit."  When  this  pressure  is  attained  the  semilunar  valves  open 
and,  with  the  propulsion  of  the  blood  onward  into  the  aorta,  the 
pressure  rises  in  both  ventricle  and  aorta  to  the  systolic  pressure. 
This  pressure  is  then  maintained  in  the  ventricle  almost  to  the  end 
of  systole,  driving  the  blood  at  an  even  rate  out  into  the  aorta  and 
into  the  smaller  vessels.  With  the  relaxation  at  the  close  of  systole 
the  pressure  in  the  ventricles  falls  to  zero  as  the  semilunar  valves 
close.  Diastole  now  commences.  The  venous  pressure  causes  the 
tricuspid  and  mitral  valves  to  open  and  the  blood  fills  the  ventricles 
at  a  rate  dependent  upon  the  venous  pressure.  The  amount  of 
distention  produced  in  the  ventricle  by  a  given  venous  pressure  is 
determined  by  the  cardiac  tone — the  greater  the  tone,  the  less  the 
distention.  When  this  inflow  is  completed  the  diastole  ])roper  ends 
and  the  remainder  of  the  cycle  is  occupied  by  a  period  of  rest  or 
diastasis. 


26  PHYSIOLOGY  OF  BLOOD-PRESSURE 

With  changes  in  cardiac  rate,  the  duration  of  both  systole  and 
diastole  are  altered,  but  the  former  much  less  than  the  latter.  The 
length  of  the  systole  in  man,  with  a  pulse  rate  of  about  75  to  95, 
is  from  0.3  to  0.38  second.  With  slow  rates  that  permit  time  for 
adequate  filling  of  the  ventricles  Henderson,^  Bohr^  and  Piitter' 
have  found  that  providing  an  adequate  venous  pressure  is  main- 
tained, the  systolic  discharge  is  under  normal  conditions  practically 
a  constant  quantity  for  any  given  individual,  and  the  changes  in 
the  rate  influence  only  the  duration  of  diastasis.  Hence  the  cardiac 
output  per  minute  under  such  conditions  will  be  proportional  to 
the  cardiac  rate.  With  a  more  accelerated  pulse  rate,  however, 
Henderson  has  shown  that  the  ventricle  has  not  sufficient  time  to 
receive  its  full  quota  of  blood  and  the  diastole  is  shortened.  In 
consequence,  the  systolic  discharge  is  diminished,  and  although  the 
volume  output  per  minute  still  increases  as  the  pulse  becomes 
more  rapid,  it  falls  farther  and  farther  behind  proportionally.  Hen- 
derson holds  to  the  view  that  the  systolic  output  of  the  heart  is 
determined  entirely  by  two  factors — the  cardiac  rate,  altering  the 
duration  of  the  diastole,  and  the  venous  pressure.  On  the  other 
hand,  Zuntz*  and  Plesch^  find  evidence  to  support  the  view  that, 
in  addition,  the  heart  is  capable  of  varying  its  output  per  minute 
independently  of  the  rate  and  of  the  venous  pressure,  as  the  result 
of  direct  changes  in  the  cardiac  tonus  and  in  the  amplitude  of  the 
cardiac  stroke. 

The  pressure  which  is  effective  in  filling  the  ventricle  of  the 
heart  is  not  the  auricular  pressure  measured  with  respect  to  the 
atmospheric  pressure,  but  is  the  difference  between  the  intra- 
auricular  and  the  intrathoracic  pressures.  This  pressure  difference 
has  been  termed  by  Henderson  and  Barringer  the  effective  venous 
pressure.  If  the  intra-auricular  pressure  is  plus  10  mm.  of  water 
and  the  intrathoracic  presstu-e  is  minus  40  mm.  of  water  then  the 
effective  venous  pressure  will  be  50  mm.  of  water. 

Henderson  and  Barringer  have  found  that  with  normal  cardiac 
tonus  the  venous  pressure  necessary  to  distend  the  right  ventricle 
as  rapidly  as  it  relaxes  is  not  more  than  50  mm.  of  water  in  excess 
of  the  intrathoracic  pressure.  This  he  calls  the  critical  venous 
pressure. 

Wiggers^  finds,  however,  that  there  exists  a  level  of  venous  press- 

»  Am.  Jour.  Physiol.,  1912-13,  xxxi,  288,  362,  399. 

*  Skand.  Arch.  f.  Physiol.,  1909,  xxii,  221. 

'Ztschr.  f.  klin.  Med.,  1911,  Ixxiii,  342. 

<Ibid.,  1912,  Ixxiv,  347. 

'  Ztschr.  f.  Physiol.,  1912,  xxvi,  90. 

'  Circulation  in  Health  and  Disease,  Philadelphia  and  New  York,  1915. 


BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR  TREE    27 

ure  (40  to  70  mm.  of  water)  which  may  be  regarded  rather  as  a 
relative jivitical  'pressure,  in  the  sense  that  changes  in  the  venous 
pressure  above  this  will  modify  the  cardiac  output  per  beat  only  to 
a  very  small  extent.  There  does  exist,  he  believes,  an  absolutely 
critical  venous  pressure,  which  he  places  at  about  150  mm.  of  water, 
beyond  which  the  heart  no  longer  increases  its  output  per  beat 
but  instead  dilates  with  diminution  in  the  output  per  beat.  Patter- 
son and  Starling  have  made  observations  that  suggest  that  some 
cases  of  absolutely  critical  venous  pressure  exist  as  high  as  200  to  250 
mm.  of  saline.  In  pathological  hearts  with  an  impaired  myocardium 
the  absolutely  critical  venous  pressure  is  probably  much  reduced. 

Studies  upon  the  dog  and  man  have  led  Henderson  to  the  view 
that  while  normally  the  pressure  in  the  intrathoracic  veins  may  dur- 
ing a  very  deep  inspiration  become  less  than  atmospheric,  it  never 
normally  becomes  less  than  45  mm.  of  water  above  the  intrathoracic 
pressure  and  therefore  falls  scarcely,  if  at  all,  below  the  critical 
pressure.  In  normal  inspiration,  the  descent  of  the  diaphragm,  by 
compressing  the  abdominal  capillaries  and  veins,  somewhat  increase? 
the  venous  flow  into  the  thorax. 

In  an  athlete,  panting  after  a  contest,  not  only  the  inspiratory 
descent  of  the  diaphragm,  but  also  the  powerful  expiratory  con- 
traction of  the  abdominal  muscles  must  hasten  the  venous  flow 
from  the  splanchnic  area  to  the  right  auricle,  and  aid  in  maintain- 
ing the  critical  venous  pressure  in  spite  of  the  accelerated  cardiac 
rate  and  hence  increased  cardiac  output.  It  is  probable  that  in 
extreme  tachycardia,  the  shortening  of  diastole  and  consequent 
imperfect  filling  of  the  ventricle  may  actually  lead  to  a  diminished 
cardiac  output  per  minute. 

Henderson  and  Prince^  from  a  study  of  the  oxygen  pulse  (the 
oxygen  consumption  by  the  body  per  minute  divided  by  the  pulse 
rate)  with  varying  amounts  of  work,  have  concluded  that  the 
systolic  discharge  of  a  well-developed  man,  working  hard  aftd  with 
a  pulse  rate  of  140  per  minute,  is  not  less  than  100  c.c.  of  blood. 

Venous  Pressure. — So  long  as  the  relative  critical  venous  pressure 
is  maintained,  the  cardiac  output  per  beat  is  dependent  upon  the 
duration  of  diastole.  At  slow  and  normal  cardiac  rates,  the  diastolic 
filling  is  complete,  but  at  accelerated  rates  the  filling  becomes  pro- 
gressively diminished.  Inadequate  venous  pressure  reduces  the 
cardiac  output.  On  the  other  hand,  in  the  presence  of  a  weakened 
heart  an  abnormally  high  venous  pressure  probably  tends  to  keep 
the  ventricles  overdistended,  thus  predisposing  to  dilatation. 

1  The  Oxygen  Pulse  and  the  Systolic  Discharge,  Am.  Jour.  Physiol.,  1914,  xxxv,  106. 


28  PHYSIOLOGY  OF  BLOOD-PRESSURE 

Cardiac  Rate. — At  slow  and  moderate  rates  the  cardiac  output 
per  minute  is  probably  proportional  to  the  cardiac  rate.  At  more 
rapid  rates  the  minute  output  increases  with  the  pulse  rate,  but  not 
proportionally.  At  extremely  rapid  rates  imperfect  ventricular 
filling  may  probably  actually  diminish  the  minute  output. 

Cardiac  Tone. — Either  unduly  diminished  cardiac  tone,  by  per- 
mitting dilatation  of  the  ventricles,  or  unduly  increased  cardiac 
tone,  by  interfering  with  the  diastolic  filling,  impairs  the  cardiac 
output. 

Stenotic  or  incompetent  valves  tend  to  diminish  the  cardiac 
output,  although  this  defect  is  at  first  compensated  by  increased 
amplitude  of  contraction  and  frequently  by  increased  rate. 

Of  these  various  factors,  changes  in  one  may  to  some  extent  be 
compensated  by  changes  in  another. 

The  elevation  of  venous  pressure  may  possibly  be  counteracted 
by  an  increase  of  cardiac  tone.  Since  Henderson's  studies,  however, 
support  the  view  that  relaxation  of  the  mammalian  heart  in  diastole 
is  caused  purely  by  the  venous  pressure,  for  the  present  the  question 
must  be  left  open,  whether  the  cardiac  tone  can  be  altered  in  the 
normal  heart  independently  of  the  venous  pressure  and  for  the 
purpose  of  compensating  for  changes  in  the  latter.  Changes  in 
cardiac  activity  can  rarely  compensate  for  the  diminished  venous 
return  resulting  from  hemorrhage,  from  stagnation  of  the  blood 
in  widely  dilated  peripheral  vessels  (vasomotor  shock)  or  from 
mechanical  obstruction  to  the  venous  return.  The  reflex  accelera- 
tion of  the  cardiac  rate  that  results  is  usually  ineffective. 

Marey  noted  that  increased  blood-pressure  is  followed  by  slowing 
of  the  pulse,  and  later  Eyster  and  Hooker^  showed  that  this  is  due 
to  vagus  stimulation  occurring  reflexly  when  the  blood-pressure 
in  the  carotids  or  the  aorta  is  increased,  even  though  changes  in  the 
cerebral  circulation  be  excluded.  The  action  of  the  vagus  upon  the 
heart  is  to  diminish  the  cardiac  rate  by  reducing  the  activity  of  the 
"pace-maker,"  and  therefore  to  decrease  the  output  per  minute, 
and  when  extreme,  to  reduce  the  conductivity  of  the  auriculo- 
ventricular  bundle,  producing  partial  or  complete  block. 

Colin,  Rothberger  and  Winterberg,  and  Ganter  and  Zahn  have 
all  shown  independently  that  the  right  vagus  depresses  especially 
the  activity  of  the  sinus  node,  the  pace-maker,  whereas  the  left 
vagus  depresses  more  particularly  the  conductivity  of  the  auriculo- 
ventricular  bundle.    Apparently  there  is  a  similar  distribution  of  the 

'  Zentralbl.  f.  Physiol.,  Leipsic  u.  Wien,  1907,  xxi,  615. 


BLOOD-PRESSURE  THROUGHOUT  THE   VASCULAR   TREE    29 

fibers  from  the  right  and  left  stellate  ganglia  which  in  their  action 
oppose  the  vagus  fibers. 

The  amplitude  of  cardiac  contraction  is  influenced  by  the 
coronary  circulation.  Increased  flow  from  the  coronary  vessels 
increases  the  cardiac  contraction,  and  this  effect  occurs,  in  part, 
at  least,  independently  of  the  increased  supply  of  nutrition  to  the 
heart  muscle.  Porter  has  shown  that  increased  intraventricular 
pressure,  although  it  tends  to  decrease  the  coronary  flow,  likewise 
excites  a  contraction  of  greater  amplitude. 

Roy  and  Adami^  have  shown,  however,  by  cardiometer  studies  that 
with  increased  aortic  and  hence  intraventricular  pressure,  even 
though  the  output  per  minute  may  be  increased,  the  residual  blood 
(that  remaining  in  the  ventricles  at  the  end  of  systole)  is  increased 
and  the  ventricles  become  more  widely  dilated  during  diastole. 
Excessive  aortic  pressure  therefore  leads  to  loss  of  ventricular  tone 
with  dilatation  and  impairment  of  cardiac  efficiency. 

Composition  of  the  Blood. — For  the  maintenance  of  the  activity 
of  the  mammalian  heart  the  presence  of  certain  nutrient  substances 
and  certain  salts  in  the  blood  stream  is  essential.  The  blood,  or  in 
perfusion  experiments  the  perfused  fluid,  must  contain  oxygen,  a 
source  of  energy  such  as  dextrose,  and  the  salts  of  sodium,  calcium, 
and  possibly  potassium.  Concerning  the  effects  of  certain  substances 
that  may  be  present  in  normal  circulating  blood  the  following 
summary  is  given  by  Wiggers:  Calcium  is  absolutely  essential;  in 
excess  it  causes  an  increased  tonus.  Barium  and  strontium  have 
similar  effects.  Potassium  is  not,  perhaps,  absolutely  necessary; 
its  influence  when  in  excess  is  to  stop  the  heart  in  extreme  relaxa- 
tion. The  presence  of  bile  slows  the  cardiac  rhythm  and  augments 
its  tonus.  Of  the  extracts  from  the  organs  of  internal  secretion, 
adrenalin  increases  the  rate  and  amplitude  of  the  perfused  heart 
and  reduces  its  tonus,  whereas  pituitary  extract  slows  the  heart, 
decreases  its  amplitude,  and  increases  its  tonus. 

Arteries. — The  elasticity  of  the  arteries,  by  virtue  of  which  they 
dilate  during  each  systole  to  accommodate  the  ventricular  output 
with  only  a  moderate  rise  of  the  pressure  within  them,  and  then 
during  diastole  contract  again,  forcing  a  continuous  stream  through 
the  capillaries  and  maintaining  under  normal  conditions  a  fair  press- 
ure throughout  diastole,  is  a  property  of  the  utmost  importance. 
Without  this  elasticity  the  strain  upon  the  cardiac  muscle  would  be 
enormously  increased,  as  would  be  the  straui  during  systole  upon 

1  British  Med.  Jour.,  1888,  ii,  321. 


30  PHYSIOLOGY  OF  BLOOD-PRESSURE 

the  vessel  walls.  Were  the  heart  pumping  into  an  absolutely  rigid 
system,  the  cardiac  systole  would  be  prolonged,  the  systolic  pressure 
enormously  increased  and  the  diastolic  pressure  would  fall  to  zero, 
with  a  cessation  of  flow  during  diastole.  The  pulse-pressure  would 
equal  the  systolic  pressure.  Such  an  extreme  condition  never 
actually  exists,  but  some  approach  toward  it  may  be  seen  in 
individuals  with  sclerotic  arteries  in  whom  often  a  systolic  press- 
ure of  200  may  be  associated  with  a  diastolic  pressure  of  130;  a 
pulse-pressure,  therefore,  of  70,  as  contrasted  with  the  normal 
pulse-pressure  of  about  30.  Obviously  this  exaggeration  of  the  pulse- 
pressure  by  rigid  vessels  will  be  less  marked  if  the  cardiac  rate  be 
increased  and  the  output  per  beat  correspondingly  diminished.  The 
pulse-pressure  is  not  infrequently  looked  upon  as  a  rough  measure 
of  the  cardiac  activity.  This  to  some  extent  it  is;  yet  we  have  just 
seen  it  is  influenced  also  to  a  marked  degree  by  the  condition  of  the 
arteries.  It  has  been  commonly  accepted  that  this  elasticity  of  the 
arteries,  while  it  results  from  the  tonus  of  their  muscular  coats,  is 
to  be  looked  upon  as  a  passive  elasticity  not  unlike  that  of  a  rubber 
tube.  Hasebroek^  has,  however,  recently  advanced  the  hypothesis 
that  while  the  dilatation  of  the  arteries  is  a  passive  result  of  the 
injected  volume  of  blood,  their  contraction  is  an  active  muscular 
act  and,  indeed,  an  important  adjunct  to  the  heart  in  the  main- 
tenance of  blood-pressure  and  blood  flow. 

Arterioles,  Capillaries,  and  Veins. — The  smaller  arterioles  together 
with  the  capillaries  constitute  the  main  resistance  in  the  circulation, 
and  are  chiefly  responsible  for  the  pi-oper  distribution  of  the  blood 
flow  to  various  organs  and  tissues,  as  the  relative  demands  of  these 
for  blood  changes  with  altering  activity.  The  blood  which  reaches 
the  smaller  arterioles  at  a  mean  pressure,  but  little  below  that  in 
the  aorta,  leaves  them  at  a  very  low  pressure,  varying  with  the 
portion  of  the  body  under  consideration.  Whether  this  fall  of 
pressure  occurs  chiefly  in  the  small  arterioles  or  in  the  capillaries 
is  a  matter  of  dispute.  The  capillaries  together  with  the  veins  of 
the  body  serve  as  a  reservoir  for  the  blood.  Complete  loss  of  tone 
in  these  vessels  leads  to  the  accumulation  in  them,  particularly  in 
the  splanchnic  region,  of  practically  all  the  blood  in  the  body.  The 
capillary  and  venous  tone  is  therefore  responsible  for  maintain- 
ing the  supply  of  blood  to  the  right  auricle  and  this,  as  we  have 
already  seen  in  considering  the  heart,  is  of  the  utmost  importance 
for  the  maintenance  of  cardiac  output  and  of  blood-pressure.    The 

•  Deutsch.  Arch.  f.  klin.  Med.,]l911,  cii,  567. 


BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR  TREE    31 

peripheral  resistance  is  the  result  of  several  factors,  including  the 
viscosity  of  the  blood  and  the  size  of  the  vessels  as  controlled  by  the 
vasomotor  system  and  by  the  extravascular  pressure,  such  as  that 
exerted  by  the  muscles  or  viscera  through  which  the  vessels  pass. 

The  Vasomotor  System. — In  this  relation  it  is  the  capillaries  and 
veins  of  the  splanchnic  area  that  are  of  greatest  significance.  This 
was  shown  experimentally  by  Ludwig  and  Thiry^  in  1864.  These 
vessels  alone  are  capable  of  containing  all  the  blood  of  the  body  and 
were  they  to  lose  their  tone  the  individual  would  promptly  "  bleed 
to  death  in  his  own  vessels,"  as  in  vasomotor  shock.  In  certain  of 
the  lower  animals  the  tone  of  these  vessels  is  relatively  low.  The 
hutch  rabbit  can  be  killed  by  simply  holding  it  by  the  ears  in  the 
vertical  position,  the  splanchnic  vessels  not  having  sufficient  tone 
to  overcome  the  force  of  gravity.  In  the  dog  manual  pressure  over 
the  abdomen  will  cause  a  prompt  rise  of  carotid  blood-pressure  of 
20  to  30  mm.  of  mercury  due  to  the  forcing  of  the  blood  from  the 
vessels  onward  to  the  right  auricle.  The  regulation  of  the  tone 
of  the  arterioles,  capillaries,  and  perhaps  veins,  is  the  most  impor- 
tant factor  toward  this  end.  This  is  brought  about  by  the  vaso- 
motor nervous  system.  The  vasomotor  system  consists  of  two  main 
parts,  the  vasoconstrictor  system  and  the  vasodilator  system. 

Vasomotor  nerves  have  been  demonstrated  anatomically  or  func- 
tionally, or  in  both  ways  in  practically  all  organs  of  the  body. 
Their  action  is,  however,  very  much  more  conspicuous  in  certain 
vessels  than  in  others.  In  the  cerebral,  pulmonary,  and  coronary 
vessels  their  action  is  difficult  to  demonstrate  and  their  presence 
in  these  vessels  was  long  disputed. 

Johansson*  observed  that  the  rise  in  arterial  pressure  accompany- 
ing the  stimulation  of  the  splanchnic  nerve,  which  carries  vaso- 
motor fibers  to  the  splanchnic  area,  does  not  consist  of  a  single  rise 
and  fall,  but  shows  two  elevations. 

Elliott'  who  investigated  this  phenomenon  in  the  cat,  ascribes 
the  second  rise  to  a  discharge  of  suprarenal  secretion  into  the  circu- 
lation, inasmuch  as  the  excitation  of  the  splanchnic  nerve  fails  to 
produce  this  second  elevation  after  the  extirpation  of  the  supra- 
renal glands.  This  hypothesis  is  further  supported  by  the  work  of 
von  Anrep.* 

*  Quoted  by  Howell:.  Text-book  of  Physiology,  Philadelphia,  1912;  Sitz.  d.  kais. 
Akad.  d.  Wiss.  math,  naturw.  CI.,  1864,  xlix,  2,  442. 

»  Arch.  f.  Anat.  u.  Phys.,  1891,  p.  103. 

*  Jour.  Physiol.,  1912,  xliv,  374. 

*  Ibid.,  xlv,  307. 


32  PHYSIOLOGY  OF  BLOOD-PRESSURE 

The  Vasoconstrictor  System. — The  first  important  experimental 
studies  upon  this  subject  were  those  of  Claude  Bernard.^  In  1851 
he  noted  the  dilatation  of  the  vessels  in  the  ear  of  the  rabbit  after 
cutting  its  cervical  sympathetic  nerve  on  the  same  side.  Later  he 
observed  that  electrical  stim^ulation  of  the  upper  end  of  the  cut 
nerve  caused  constriction  of  these  dilated  vessels.  Thus  was  demon- 
strated the  existence  of  vasoconstrictor  nerves. 

The  vasoconstrictor  system  consists  of  a  centre  in  the  medulla 
which  is  connected  with  the  vessels  of  the  body  by  nerve  paths,  each 
consisting  of  three  neurons.  In  the  medulla  beneath  the  middle 
of  the  fourth  ventricle  exists  the  bilateral  nerve  centre  which  is 
chiefly  responsible  for  the  maintenance  of  vasomotor  tone.  This 
centre  is  continuously  in  a  state  of  tonic  activity  which  at  times 
undergoes  rhythmic  fluctuations,  giving  rise  to  the  Traube  waves, 
to  be  described.  Porter  has  recently  found  evidence  against  the 
view  that  both  the  arterial  tonus  and  the  vasomotor  reflexes  follow- 
ing stimulation  of  afferent  nerves  are  controlled  by  the  same  master 
cells,  the  so-called  vasomotor  centre.  He  has  been  able  by  the  use 
of  curare  in  cats  to  more  than  double  the  sciatic  and  the  depressor 
reflex  change  in  blood-pressure,  while  the  arterial  tonus  is  left  sub- 
stantially unchanged.  Possibly,  therefore,  we  may  be  compelled 
to  recognize  two  centres,  a  vasotonic  and  a  vasoreflex  centre,  related 
but  separable.^  The  axons  leading  from  these  medullary  cells 
pass  down  the  cord  to  end  around  cells  of  the  anterior  horn,  from 
the  upper  thoracic  level  to  the  upper  lumbar,  and  constitute,  with 
the  medullary  cell,  the  first  neuron.  The  axons  of  the  anterior  horn 
cells  are  medullated  and  constitute  the  second  neuron  in  the  chain, 
the  so-called  preganglionic  fibers.  They  pass  from  the  cord  in  the 
white  rami  communicantes  from  the  first  thoracic  to  the  second  or 
fourth  lumbar  segments,  and  entering  the  sympathetic  chain,  have 
one  of  three  destinations.  Those  destined  for  the  extremities  end 
around  cells  in  the  sympathetic  chain.  The  non-medullated  fibers 
of  these  sympathetic  cells  constitute  the  third  neuron,  the  post- 
ganglionic fibers.  They  pass  by  the  gray  rami  communicantes  back 
to  the  spinal  cord  and  thence  accompany  the  appropriate  spinal 
nerves  to  their  destination.  The  preganglionic  fibers  destined  for 
the  deeper  vessels  of  the  head  pass  through  the  white  rami  of  the 
first  to  sixth  thoracic  segments  and  up  the  sympathetic  to  the 
superior  cervical  ganglion.  From  this  point  the  associated  postgan- 
glionic fibers  are  distributed  through  the  carotid  and  other  vascular 

•  Lefons  sur  les  liquides  de  I'organisme,  Paris,  1859. 
» Am.  Jour.  Physiol.,  1914-15;  xxxvi,  418. 


BLOOD-PRESSURE  THROUGHOUT  THE   VASCULAR   TREE    33 

plexuses.  The  preganglionic  fibers  destined  for  the  vessels  of  the 
abdominal  and  pelvic  viscera,  the  most  important  of  all  in  the 
regulation  of  blood-pressure,  pass  directly  through  the  sympathetic 
chain  and  by  way  of  the  splanchnic  nerves  to  the  celiac,  inferior 
mesenteric,  or  other  large  prevertebral  ganglia*.  From  these  gan- 
glia the  postganglionic  fibers  are  distributed  to  the  plexuses  around 
the  abdominal  vessels.  Section  of  the  first  neuron  in  this  chain,  as 
by  section  of  the  cervical  cord,  leads  to  extreme  loss  of  vascular 
tone  with  fall  in  blood-pressure,  failure  of  the  circulation,  and  death. 
If  the  circulation  be,  however,  artificially  maintained  after  section 
of  the  cervical  cord,  the  spinal  cells,  the  second  neurons,  gradually 
assume  a  moderate  tonic  acitivity  and  restore  a  very  imperfect 
vascular  tone.  This  may  in  turn  be  destroyed  by  destruction  of 
the  spinal  cord. 

Finally,  Goltz^  has  shown  that  even  after  destruction  of  the  cord, 
some  vascular  tone  may  be  recovered  which  must  be  attributed  to 
tonic  activity  either  of  the  third  postganglionic  neuron  or  of  the 
musculature  of  the  vessel  wall.  Excitation  of  the  vasoconstrictor 
centre  with  contraction  of  the  peripheral  vessels  is  called  forth  by 
the  stimulation  of  pressor  fibers,  which  may  be  demonstrated  in 
almost  any  large  nerve  containing  afferent  fibers,  but  especially  in 
the  cutaneous  nerves.  These  pressor  fibers  may  be  stimulated  by 
electricity,  by  cold  applied  to  the  skin,  and  in  other  ways.  Depres- 
sion of  the  centre  with  diminished  contraction  of  the  vessels  is 
called  forth  by  stimulation  of  other  afferent  fibers,  called  depressor 
fibers.  These  likewise  may  be  demonstrated  in  many  of  the  large 
afferent  nerves.  Thus,  application  of  warmth  to  the  skin  leads  to 
local  vascular  dilatation,  the  result  of  stimulation  of  depressor 
fibers.  Sensory  stimuli  from  certain  regions,  notably  the  middle 
ear  and  the  testis,  give  rise,  as  a  rule,  to  depressor  effects.  Electric 
stimulation  of  the  central  end  of  the  cut  sciatic  or  of  the  splanchnic 
nerve  may  lead  to  either  pressor  or  depressor  effects. 

Since  mental  work  or  especially  mental  interest  leads  to  a  con- 
striction of  the  bloodvessels  with  a  rise  of  blood-pressure,  it  seems 
likely  that  pressor  and  probably  also  depressor  fibers  pass  from  the 
cortical  centres  to  the  vasoconstrictor  centre.  Medullary  anemia 
and  increased  CO2  concentration  of  the  medullary  blood  are  both 
potent  stimulants  to  the  vasoconstrictor  centre.  jNIany  drugs  exert 
a  direct  effect  upon  this  centre.  Ludwig  and  Cyon,^  in  18G6,  demon- 
strated in  the  rabbit  the  so-called  depressor  nerre  of  the  heart. 

>  Arch,  f .  d.  gesamt.  Physiologie,  1896,  Ixiv,  397. 

*Bericht  d.  sachsisch.  Gesellsch.  d.  Wissensch.  math.  Phys.  CI.,  1866,  p.  315. 
3 


34  PHYSIOLOGY  OF  BLOOD-PRESSURE 

This  is  an  afferent  nerve  running  in  the  sheath  with  the  vagus,  or 
in  other  species  forming  a  part  of  the  vagus.  Stimulation  of  its 
peripheral  cut  end  is  without  effect,  but  of  its  central  end,  leads  to 
depression  of  the  vasomotor  centre  and  stimulation  of  the  cardio- 
inhibitory  centre,  tending  to  lower  blood-pressure.  It  is  supposed 
to  exert  a  steadying  effect  upon  blood-pressure  and  to  be  stimulated 
mechanically  by  increase  of  aortic  pressure.  The  older  view  that  it 
was  stimulated  chiefly  by  intraventricular  pressure  has  been  ren- 
dered improbable  by  the  work  of  Eyster  and  Hooker. ^  Einthoven^ 
has  found  an  impulse  passing  up  this  nerve  with  every  cardiac  beat. 

The  Vasodilator  System. — It  was  likewise  Claude  Bernard'  who 
first  recognized  the  existence  of  vasodilator  nerves.  He  noted  that 
stimulation  of  the  peripheral  end  of  the  cut  chorda  tympani  nerve 
caused  great  dilatation  of  the  bloodvessels  of  the  submaxillary  gland, 
with  increased  flow  through  the  afferent  vein;  this  vein  in  some  cases 
actually  pulsated.  Dilator  fibers  have  been  demonstrated  in  certain 
of  the  cranial  nerves  and  in  the  sympathetic  chain.  The  chorda 
tympani  conveys  such  fibers  from  the  facial  nerve  for  distribution 
to  the  submaxillary  and  sublingual  glands  and  the  anterior  two- 
thirds  of  the  tongue.  The  glossopharyngeal  nerve  carries  such 
fibers  to  the  posterior  third  of  the  tongue,  the  tonsils,  pharynx,  and 
parotid  gland. 

From  the  cervical  sympathetic  dilator,  fibers  pass  to  the  lips, 
gums,  palate  and  skin  of  the  face,  passing  through  the  Gasserian 
ganglion  and  thence  with  the  fifth  nerve.  From  the  thoracic  sym- 
pathetic dilator,  fibers  pass  through  the  splanchnic  nerves  to  the 
abdominal  viscera.  From  the  first  to  third  sacral  segments  of  the 
cord  dilator  fibers  pass  to  the  hypogastric  plexus,  whence  as  the 
nervi  erigentes  they  supply  the  penis,  and  when  stimulated  cause 
erection.  The  existence  of  dilator  fibers  to  the  limbs,  first  upheld 
by  Goltz,  has  been  rendered  uncertain  by  the  work  of  Bayliss.* 
Both  types  of  efferent  fibers,  vasoconstrictor  and  vasodilator,  may 
exist  in  the  same  nerve,  for  example,  in  the  splanchnic.  As  a  rule 
these  fibers  react  to  different  types  of  electrical  stimulation,  the 
dilators  responding  to  weaker  and  to  more  slowly  interrupted  cur- 
rents, responding  less  promptly,  and  once  having  done  so,  showing 
a  more  prolonged  reaction  than  do  the  constrictor  fibers.  More- 
over, a  few  days  after  section  of  such  a  nerve  the  irritability  of  the 
constrictor  fibers  is  lost,  while  that  of  the  dilators  is  still  retained. 

There  is  no  evidence  that  there  exists  one  general  vasodilator 

*  Loc.  cit.  *  Quoted  by  Howell.  *  Loc.  cit. 

«  Jour.  Physiol.,  1900,  xxvi,  173;  ibid.,  1902,  xxviii,  276. 


BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR  TREE    35 

centre  associated  with  the  dilator  nerves,  but  rather  that  there  are 
many  centres  through  the  cerebrospinal  axis  for  the  various  areas 
supplied.  Probably  the  vasodilator  system  is  of  less  significance 
in  the  regulation  of  the  general  blood-pressure,  but  is  concerned  in 
local  augmentation  of  blood  flow  in  response  to  local  needs,  a^  in 
increased  glandular  or  muscular  activity.  So  far  as  we  know  there 
is  no  tonic  activity  of  the  vasodilators.  How  the  stimulation  of  the 
dilator  fibers  leads  to  dilatation  of  the  vessels  is  a  subject  of  specu- 
lation. Howell  has  contended  that  it  is  probably  by  direct  inhibi- 
tion of  the  muscles  in  the  vessel  walls. 

Chemical  Regulation. — The  possibility  of  a  chemical  regulation 
of  vascular  tone  has  attracted  some  attention.  Gaskell  has  shown 
that  acids  in  low  concentration  cause  vascular  dilatation,  and  in 
this  connection  the  local  action  of  lactic  acid  and  carbon  dioxide 
generated  during  muscular  activity  has  been  suggested. 

The  idea  that  a  continued  pouring  of  epinephrin  from  the  adrenal 
glands  into  the  circulation  is  a  factor  in  the  maintenance  of  normal 
vascular  tone  is  now  questioned.  Hoskins  and  McClure^  have 
obtained  no  fall  in  blood-pressure  after  ligation  of  the  adrenal  vessels. 
They  have  also  found  that  an  amount  of  epinephrin  in  the  circula- 
tion sufficient  to  affect  the  blood-pressure  is  enough  to  cause  sup- 
pression of  intestinal  peristalsis.  The  various  studies  tending  to 
show  by  one  test  or  another  that  there  is  adrenalin  demonstrable  in 
the  circulating  blood  have  been  shown  by  Stewart,  O'Connor, 
Schultz,  and  Janeway  and  Park  to  be  based  on  unreliable  methods, 
and  as  Janeway  and  Park^  assert,  at  the  present  time  there  is  no 
evidence  that  epinephrin,  in  amounts  sufficient  to  produce  its  phy- 
siological effects  upon  any  hitherto  used  test  objects,  exists  in  the 
circulating  blood,  with  the  exception  of  the  blood  from  the  supra- 
renal vein.  Cannon's^  recent  work,  indicating  that  after  excitement 
in  cats  there  is  an  increased  output  of  adrenal  secretion,  suggests 
that  this  may  be  a  factor  in  the  rise  of  general  arterial  pressure  inci- 
dent to  excitement  or  exertion.  As  to  the  action  of  other  organs  of 
internal  secretion  upon  the  maintenance  or  regulation  of  blood- 
pressure  the  findings  are  inconclusive.  Extracts  of  the  pituitary 
gland  produce  on  injection  a  brief  fall  in  blood-pressure,  followed  by 
a  rise.  The  depressor  substance  is  related  to  cholin.^  The  pressor 
substance  differs  somewhat  in  its  effects  from  that  obtained  from 
the  adrenals.  Extracts  of  various  mammalian  tissues,  thyroid,  liver, 

» Am.  Jour.  Physiol.,  1911-12,  xxx,  192;  ibid.,  1912-13,  xxxi,  59. 

*  Jour.  Exper.  Med.,  1912,  xvi,  541.  'Am.  Jour.  Physiol.,  1913,  xxxii,  44. 

*C.  J.  Wiggers:  Am.  Jour.  Med.  Sc,  1911,  cxli,  602. 


30  PHYSIOLOGY  OF  BLOOD-PRESSURE 

pancreas,  thymus,  testis,  bone  marrow,  the  intestine  from  various 
levels,  parathyroid,  brain,  prostate,  ovary,  in  the  hands  of  most 
observers  produce  on  injection  a  fall  of  blood-pressure.^  This  fall 
may  be  due  in  some  instances  to  the  presence  of  cholin.  A  pressor 
substance  has  been  obtained  from  the  kidney,  and  certain  observers 
with  some  of  the  above-mentioned  organs  from  certain  mammals 
have  obtained  pressor  instead  of,  or  in  addition  to,  depressor  effects. 
This  action  of  tissue  extracts  from  such  diverse  sources  is  not, 
however,  to  be  understood  to  mean  that  these  organs  are  during 
life  pouring  into  the  blood  stream  substances  serving  to  influence 
and  regulate  blood-pressure.  We  have  no  proof  that  the  substance 
extracted  from  these  organs  ever  pass  normally  from  them  into  the 
blood  stream,  nor  that  they  have  anything  to  do  with  the  regulation 
of  blood-pressure. 

The  Blood  and  the  Lymph. — Within  a  wide  range  the  tonus  of  the 
capillaries  and  veins  compensates  for  changes  in  the  total  volume 
of  blood.  Thus,  2.8  per  cent,  of  the  body  weight,  or  about  one- 
third  of  the  entire  volume  of  an  animal's  blood,  may  be  withdrawn 
without  any  fall  in  the  arterial  pressure.  Upon  the  withdrawal  of 
a  somewhat  larger  quantity,  however,  the  capillaries  and  veins  no 
longer  can  maintain  an  adequate  supply.to  the  right  auricle.  Dimin- 
ution in  the  cardiac  output  results  and  the  arterial  pressure  falls. 

The  effect  on  blood-pressure  of  the  infusion  of  normal  saline 
intravenously  depends  upon  whether  the  pressure  is  normal  or  low 
at  the  time  of  the  introduction.  If  the  pressure  be  normal,  Cohn- 
heim  showed  that  large  quantities  of  normal  saline  may  be  intro- 
duced intravenously  with  only  very  slight  and  transitory  elevation 
of  blood-pressure.  This  is  because  the  fluid  introduced  is  rapidly 
removed  by  the  kidneys  and  intestines.  When,  however,  the  blood- 
pressure  is  much  below  normal,  either  as  the  result  of  loss  of  vaso- 
motor tone  or  of  hemorrhage,  the  effect  of  introduction  of  normal 
saline  is  considerable  and  is  persistent.  The  injection  of  defibrinated 
blood,  however,  as  Mall  has  shown,  always  produces  a  marked  rise 
of  blood-pressure.  It  is  possible  by  this  means  to  raise  and  main- 
tain the  aortic  pressure  very  considerably  above  normal.  This 
is  probably  due  to  the  content  of  colloidal  substances  in  the  blood 
which  cannot  be  removed  by  kidney  or  intestine  and  which,  being 
retained,  retain  the  fluid  also.  Knowlton^  has  shown  that  intra- 
venous injection  of  colloidal  solutions,  such  as  gelatin,  causes  a 
similar  persistent  rise  of  blood-pressure  without  diuresis. 

1  J.  M.  Miller  and  E.  M.  Miller:   Jour.  Physiol.,  1911,  xliii,  242. 

2  Jour.  Physiol.,  1911,  xliii,  219. 


BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR  TREE    37 

That  the  lymphatic  system  to  some  extent  acts  as  a  regulator  of 
the  amount  of  blood  is  unquestionable.  Its  action,  however,  is 
not  very  rapid  and  is  limited  in  extent.  It  has  been  demonstrated 
that  a  rise  in  arterial  blood-pressure  is  associated  with  increase  in 
the  proportion  of  erythrocytes,  leukocytes,  and  dry  substance  of 
the  blood,  while  a  fall  in  arterial  blood-pressure  results  in  decrease 
in  the  proportion  of  these  elements.  This  is  probably  largely  to  be 
explained  by  passage  of  the  fluid  elements  of  the  blood  into  the 
lymphatic  channels  or  vice  versa — a  transfer  which  has  been  supposed 
to  take  place  chiefly  in  the  lungs. 

Viscosity  of  the  Blood. — Increase  in  the  viscosity  of  the  blood 
increases  the  resistance  to  its  passage  through  the  vessels  and  in 
consequence  tends  to  the  elevation  of  blood-pressure,  and  vice  versa. 
Clinically,  thus  far,  no  definite  relationship  has  been  established 
between  the  degree  of  hemic  viscosity  and  the  height  of  blood- 
pressure. 

Blood-pressure  and  Blood  Flow. — By  the  velocity  of  blood  flow  at 
any  point  is  meant  the  rate  at  which  the  blood  column  is  passing 
that  point.  In  the  aorta  near  the  heart  the  velocity  is  great  during 
the  systole  and  almost  zero  during  diastole.  As  the  smaller  arteries 
are  approached  the  velocity  becomes  less  during  systole  and  greater 
during  diastole  until  in  the  capillaries  and  smaller  veins  the  velocity 
is  constant  throughout  the  cardiac  cycle.  The  average  velocity 
decreases  on  passing  from  the  heart  to  the  capillaries  since  the  total 
cross-section  of  the  capillaries  is  far  greater  than  the  cross-section 
of  the  aorta.  The  average  velocity  increases  on  passing  from  the 
capillaries  to  the  large  veins  as  the  total  cross-section  of  the  venous 
bed  diminishes.  The  maximum  velocity  of  flow  in  the  larger  arteries 
of  the  horse  during  systole  has  been  found  to  be  about  520  mm. 
per  second.  The  average  velocity  of  flow  in  the  dog  has  been  found 
to  be  about  250  mm.  per  second  in  the  large  arteries,  about  GO 
mm.  per  second  in  the  femoral  and  renal  veins,  and  about  150  mm. 
per  second  in  the  jugular  vein. 

By  volume  flow  of  the  blood  is  meant  the  amount  of  blood  passing 
tlirough  an  organ  or  vessel  in  a  unit  time.  The  volume  flow  per 
minute  is  called  the  minvte  volume.  In  studying  the  minute  volume 
of  blood  flow  in  organs  or  parts  of  the  body  it  is  frequently  desir- 
able to  express  the  minute  volume  per  100  grams  of  substance. 
Obviously,  the  minute  volume  in  the  first  part  of  the  aorta  equals 
the  pulse  volume  (the  output  per  cardiac  beat)  multiplied  by  the 
cardiac  rate  per  minute,  and  is  also  the  total  volume  flow  for  the 
entire  body. 


38  PHYSIOLOGY  OF  BLOOD-PRESSURE 

The  purpose  of  blood-pressure  is  the  maintenance  of  blood  flow. 
The  volume  flow  between  two  points  is  determined  solely  by  the 
difference  of  blood-pressure  between  these  points  and  by  the  resist- 
ance to  be  overcome  in  the  connecting  vessels.  An  increased 
difference  of  blood-pressure  between  two  points  with  the  same 
resistance  must  result  in  an  increased  volume  flow  from  the  one  to 
the  other.  Unaltered  difference  of  blood-pressure  between  two 
points  with  diminished  resistance  will  likewise  result  in  an  increased 
volume  flow  from  the  one  to  the  other.  Increase  in  the  physiolog- 
ical activity  of  any  organ  of  the  body  demands  an  increased  volume 
flow  through  the  organ.  Practically  all  physiological  changes  in  the 
resistance  in  the  arterioles  and  capillaries,  and  in  the  arterial  blood- 
pressure,  are  to  be  looked  upon  as  the  normal  mechanism  for  secur- 
ing the  proper  distribution  of  blood  to  the  various  organs  and  tissues 
of  the  body. 

It  is  clear,  however,  that  volume  flow  is  not  proportional  to 
blood-pressure  alone.  Indeed,  abnormally  high  blood-pressure  may 
be  associated  with  a  diminished  volume  flow  due  to  an  abnormal 
degree  of  resistance  in  the  peripheral  vessels.  This  may  be  illus- 
trated by  contrasting  the  effects  (1)  of  abdominal  pressure  (which 
forces  blood  from  the  capillaries  and  veins  of  the  abdominal  viscera 
to  the  heart  with  an  increase  of  the  effective  venous  pressure  at 
the  heart,  and  an  increased  systolic  output)  with  (2)  the  adminis- 
tration of  adrenalin  (which  by  constriction  of  the  arterioles  increases 
the  peripheral  resistance).  Both  procedures  elevate  the  blood- 
pressure  but  they  have  opposite  effects  upon  the  pulse-pressure  and 
upon  the  volume  flow  through  certain  vascular  areas. 


Abdominal 


Mean  aortic  pressure 
Systolic  aortic  pressure  . 
Diastolic  aortic  pressure 
Aortic  pulse-pressure 
Aortic  volume  flow    . 
Mesenteric  volume  flow 
Renal  volume  flow    . 
Brain  volume  flow     . 


I  equals  increased.     D  equals  diminished. 


Adrenalin. 

I 

I 

I 

D 
D 
D 
D 

I 


The  following  tables  copied  from  Wiggers^  gives  an  idea  of  the 
approximate  volume  flow  through  various  parts  of  the  body  per 
100  gm.  of  substance. 

1  Circulation  in  Health  and  Disease,  Philadelphia  and  New  York,  1915,  p.  78. 


BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR  TREE     39 


Minute  Volume  per  100  Gkams  Substance. 


Posterior  extremity     . 
Skeletal  muscles    . 

Heart 

Head 

Stomach      .... 

Liver  (arterial) 

Portal  organs  (combined) 

Intestine 

Spleen   . 

Liver  (venous) 

Pancreas 

Liver  (total) 

Brain 

Kidney 

Thyroid 


5 . 0  c.c.  Tschuewsky. 

12.0  c.c.  Tschuewsky. 

16 . 0  c.c.  Bohr  and  Henriqufes. 

20.0  c.c.  Bohr  and  Henriqufes. 

21.0  c.c.  Burton  Opitz. 

25.0  c.c.  Burton  Opitz. 

30 . 6  c.c.  Burton  Opitz. 

31.0  c.c.  Burton  Opitz. 

58.0  c.c.  Burton  Opitz. 

59.0  c.c.  Burton  Opitz. 

80 . 0  c.c.  Biu"ton  Opitz. 

84 . 0  c.c.  Burton  Opitz. 

136.0  c.c.  Jenson. 

150.0  c.c.  Burton  Opitz. 

560.0  c.c.  Tschuewsky. 


Systolic,  Diastolic,  and  Mean  Pressure. — In  the  discussion  so  far 
we  have  considered  chiefly  the  effects  of  various  factors  upon  mean 
blood-pressure  and  the  relation  of  mean  blood-pressure  to  blood 
flow.  Inasmuch,  however,  as  in  clinical  work  it  is  not  the  mean 
pressure  but  the  systolic  and  diastolic  pressure  that  we  measure, 
the  relation  of  these  to  the  mean  pressure  under  various  circum- 
stances must  be  considered.  As  already  stated,  there  is  no  constant 
numerical  relation  between  these  three  phases  of  blood-pressure  that 
makes  it  possible  from  any  two  to  calculate  the  third.  It  may  be 
affirmed,  however,  that  the  mean  pressure  follows  more  closely  in 
its  fluctuations  the  diastolic  pressure  than  it  does  the  systolic,  and 
the  study  of  the  diastolic  pressure  is  therefore  in  many  ways  of 
greater  value  than  is  that  of  the  systolic.  Dawson's^  rule  for 
roughly  estimating  the  mean  pressure  in  man  is  to  add  one-third  of 
the  pulse-pressure  to  the  diastolic  pressure.  Using  an  artificial 
circulation  model,  Wiggers  has  studied  the  effects  of  varying  the 
peripheral  resistance,  the  cardiac  rate  and  the  cardiac  output  upon 
the  systolic,  diastolic  and  pulse-pressure.  The  effects  are  tabulated 
by  him  as  follows: 


Increased  peripheral  resistance 
Decreased  peripheral  resistance 
Increased  heart  rate    ... 
Decreased  heart  rate  ... 
Increased  systolic  discharge  . 
Decreased  systolic  discharge 


Systolic 

Diastolic 

Pulse- 

pressure. 

pressure. 

pressure. 

+ 

+  + 

— 

— 



+ 

+ 

+  + 

— 

— 



+ 

+  + 

+ 

+ 

The  systolic,  diastolic  and  pulse-pressures  are  altered  in  the  same 
direction  by  most  procedures — not,  however,  always  to  the  same 
extent.    Under  some  circumstances,  for  example,  in  aortic  regur- 


'  Loc.  cit. 


40  PHYSIOLOGY  OF  BLOOD-PRESSURE 

gitation,  this  is  not  the  case,  for  the  diastolic  pressure  is  lowered 
while  the  systolic  pressure  is  increased.  In  the  average  normal 
individual  at  rest  the  diastolic  pressure  is  70  per  cent,  of  the  systolic 
pressure,  but  in  not  a  few  normal  cases  it  may  be  as  high  as  85 
per  cent. 

Pulse-pressure.  —  The  pulse-pressure  is  with  qualifications  an 
indication  of  the  cardiac  output  per  beat.  As  a  rule  increased 
ventricular  output  leads  to  increased  pulse-pressure  and  vice  versa. 
The  pulse-pressure  normally  ranges  between  35  and  50  mm.  Hg. 
With  very  few  exceptions  it  should  not  fall  below  20  per  cent,  of 
the  diastolic  pressure.  The  attempt  has  been  made  to  establish 
formulas  enabling  one  from  the  pulse-pressure  and  the  cardiac  rate 
to  estimate  alterations  in  the  cardiac  output  per  minute — in  other 
words,  of  the  blood  flow  from  the  heart.  As  a  rule,  changes  in  the 
pulse-pressure  and  in  the  aortic  volume  flow  are  in  the  same  direc- 
tion; but  this  is  not  always  true.  For  example,  in  aortic  regurgita- 
tion, in  which  the  pulse-pressure  is  extremely  high,  the  volume 
flow  through  the  aorta  is  usually  approximately  normal,  being 
possibly  a  little  higher  or  a  little  lower  than  normal,  but  not  exhib- 
iting an  increase  in  any  sense  proportional  to  that  of  the  pulse- 
pressure.  Arteriosclerosis  also,  increasing  as  it  does  the  rigidity  of 
the  vessels,  tends  to  produce  a  somewhat  increased  pulse-pressure 
with  a  somewhat  diminished  volume  flow.  Moreover,  only  under 
very  limited  conditions  is  there  any  constant  quantitative  relation 
between  the  respective  changes  in  these  factors.  Hence  all  attempts 
aiming  to  express  in  figures  the  blood  flow  on  the  basis  of  the  pulse- 
pressure  should  be  regarded  with  suspicion. 

Effects  of  Respiration  on  Blood-pressure. — Ludwig,^  in  1847,  first 
showed  that  respiration  affects  the  aortic  pressure.  The  following 
analysis  of  these  effects  is  from  Tigerstedt.^ 

When  the  vagi  are  cut  and  the  lungs  are  being  artificially  venti- 
lated, the  capillaries  of  the  lungs  are  compressed  as  the  lungs  are 
inflated,  and  dilated  as  the  lungs  are  emptied.  The  first  effect  of 
inflation  is  therefore  to  drive  the  blood  from  the  pulmonary  capil- 
laries on  into  the  left  ventricle  (A)  with  increased  output  and  rise 
of  aortic  pressure.  The  capillary  constriction  then  acts  as  a  dam  to 
further  transmission  of  blood,  the  inflow  to  the  left  ventricle  dimin- 
ishes and  aortic  pressure  falls  {B).  This  is  still  more  marked  when 
the  lungs  are  first  deflated  and  the  capacity  of  the  pulmonary 
capillaries  is  increased  (C).     Once  they  become  filled,  however, 

1  Arch.  f.  Anat.  u.  Physiol.,  1847,  vi,  242. 
'  Lelirbuch  des  Kreislaufes,  1893. 


BLOOD-PRESSURE  THROUGHOUT  THE   VASCULAR  TREE    41 

they  readily  transmit  a  liberal  supply  to  the  left  heart  and  the 
aortic  pressure  rises  (D),  to  be  still  further  increased  as  inflation 
again  begins  (yl).  If  respiratory  movement  be  made  very  rapid, 
the  phases  B  and  D  are  eliminated  and  the  highest  pressure  comes 
at  the  end  of  inspiration,  the  lowest  at  the  end  of  expiration  (Fig.  7) . 
In  natural  respiration  the  relations  are  altered.  During  inspira- 
tion the  pulmonary  capillaries  are  first  distended  and  while  filling 
with  blood  retard  its  onflow  (^1),  but  when  dilated  permit  a  ready 
flow  through  to  the  left  heart  (B);  with  the  beginning  of  expiration 


inspiration         expiration       inspiration     expiration 
Fig.  7 

they  are  compressed,  emptied  into  the  left  heart  with  elevation  of 
the  aortic  pressure  (C),  but  during  the  remainder  of  expiration  they 
offer  considerable  resistance  to  the  onflow  of  the  blood  ( D)  (Fig.  8). 

Erlanger  and  Festerling^  find  the  phases  A  and  C  so  long  as  to 
almost  do  away  with  phases  B  and  D.  They  note  toward  the  end 
of  inspiration  an  acceleration  of  cardiac  rate  which  tends  to  increase 
aortic  pressure,  and  toward  the  end  of  expiration  a  retarding  of 
cardiac  rate. 

These  changes  in  cardiac  rates,  first  noted  by  Ludwig,  do  not 
occur  if  the  vagi  have  been  cut;  they  are  therefore  reflex  phenomena. 
Einhodt,  Talma,  Kronecker  and  Heinricius  believe  the  aspiration 


INSPIRATION  EXPIRATION  INSPIRATION  EXPIRATION 

Fig.  8 

of  blood  into  the  thorax  during  natural  inspiration  tends  to  increase 
diastolic  filling,  and  diminish  systolic  emptying  with  a  lowering  of 
blood-pressure,  and,  vice  versa,  in  expiration.  Fredericq  has  shown 
that  if  in  an  animal  with  artificial  respiration  and  cut  vagi  and 
phrenics  the  artificial  respiration  be  suspended,  respiratory  move- 
ments of  the  thoracic  wall  occur.  These  are,  of  course,  without 
eft'ect  either  on  the  pulmonary  blood  flow  or  ventilation.  IIowe\er, 
during  the  inspiratory  movement  a  fall  of  aortic  [)ressure  occurs; 

«  Jour.  Exper.  Med.,  1912,  xv,  370. 


42  PHYSIOLOGY  OF  BLOOD-PRESSURE 

during  the  expiratory  movement,  a  rise.  These  changes  can  only 
be  explained  as  effects  arising  from  the  vasomotor  centre  which 
induce  alterations  in  peripheral  resistance.  There  is  therefore  a 
coordination  between  the  three  centres,  the  respiratory,  cardio- 
inhibitory,  and  vasomotor  as  follows: 

Respiratory.  Vasoconstrictor.  Cardio-inhibitory. 

Inspiration  Inhibition  (dilatation)  Cardiac  acceleration 

Expiration  Stimulation  (constriction).  Cardiac  retardation 

Obviously  the  changes  in  the  cardio-inhibitory  and  vasomotor 
centres  have  opposite  effects  on  the  blood-pressure.  Fredericq's'^ 
experiment  shows  that  these  changes  are  not  due,  as  Schiff  sup- 
posed, to  changes  in  the  gases  of  the  blood,  the  result  of  pulmonary 
ventilation. 

The  inspiratory  fall  of  the  diaphragm  raises  abdominal  pressure, 
and  serves  as  an  adjunct  to  the  aspirating  action  within  the  thorax 
in  sending  the  blood  from  the  abdomen  into  the  thorax. 

Henderson  has  concluded  from  recent  experimental  studies  that 
the  variations  in  arterial  pressure  are  of  the  same  character  and 
bear  the  same  relations  to  the  phases  of  respiration  in  an  animal 
which  is  breathing  spontaneously  after  the  chest  has  been  opened, 
as  in  a  subject  with  the  thorax  intact.  This  would  argue  against 
the  importance  of  the  changes  in  intrathoracic  pressure  as  an 
explanation  of  the  respiratory  changes  in  arterial  pressure.  He 
concludes  that  with  normal  venous  pressure,  the  respiratory  varia- 
tions of  blood-pressure  are  always  accompanied  by  and  are  due  to 
associated  changes  in  pulse  rate,  accelerated  rate  causing  higher 
pressure.  On  the  other  hand,  with  a  deficient  venous  pressure,  such 
as  exists  frequently  under  experimental  conditions,  after  hemor- 
rhage or  in  shock,  forcible  expiratory  contractions  of  the  diaphragm 
may  increase  the  venous  pressure  sufficiently  to  more  than  compen- 
sate for  a  slower  pulse  rate  during  expiration. 

In  animals  under  experimental  conditions,  the  pulse  as  already 
noted,  usually  quickens  during  inspiration  and  slows  during  expira- 
tion. In  man  not  only  this  relation  but,  according  to  Putzig,^  the 
exact  opposite  and  many  intermediate  synchronisms  likewise  occur. 
Henderson  and  Barringer  find,  however,  that  in  the  large  major- 
ity of  their  studies  both  from  man  and  animals,  no  matter  what 
the  relation  of  pulse  rate  to  respiratory  phase  may  be,  arterial 
pressure  rises  with  the  cardiac  acceleration  and  falls  with  retardation. 

1  Arch.  Ital.  de  Biologie,  1882,  iii,  55. 

*Zt8chr.  f.  exper.  Path.  u.  Therap.,  1912,  xi,  115. 


BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR  TREE    43 

Summing  up  the  typical  effects  of  respiration  on  the  cardio- 
vascular system  under  normal  conditions  we  find: 

Inspiration :' First,  fall  of  aortic  pressure;  second,  cardiac  accel- 
eration, possibly  slight  rise  of  aortic  pressure. 

Expiration:  First,  rise  of  aortic  pressure;  second,  cardiac  retarda- 
tion, possibly  slight  fall  of  aortic  pressure. 

These  fluctuations  of  pressure,  synchronous  with  respiration,  con- 
stitute the  second  order  of  blood-pressure  oscillations.  In  normal 
individuals  these  waves  are  a  negligible  factor  in  clinical  observa- 
tions, but  in  labored  respiration  they  may  mount  to  8  to  10  mm. 

Pressure  in  the  Pulmonary  Circulation. — Wiggers  has  recently 
reviewed  the  data  upon  this  subject.  He  found,  using  a  maximum 
and  minimum  manometer,  that  the  maxium  pressure  in  a  series  of 
animals  studied  averaged  31.3  mm.  Hg.;  the  minimum  5.9  mm.  Hg., 
with  a  mean  pressure  of  19  mm.  Hg.  During  apnea  the  maximum 
pressure  falls  and  the  minimum  increases,  so  that  less  variation  of 
pressure  is  observed  in  the  pulmonary  circulation  during  a  period 
of  apnea.  Variations  in  the  length  of  the  cardiac  cycle  between 
0.6  second  and  0.9  second,  such  as  occur  normally  from  beat  to  beat, 
are  without  influence  upon  the  diastolic  pressure  in  the  pulmonary 
artery,  and  have  only  little  influence  upon  the  systolic  pressure. 
Whenever,  however,  the  output  of  the  right  heart  increases,  whether 
this  be  due  to  an  increase  in  the  venous  pressure  or  to  some  influence 
modifying  the  contraction  of  the  heart,  the  pressure  is  increased 
in  the  pulmonary  artery  and  the  flow  augments.  This  increase  in 
pressure  and  flow  also  extends  to  the  pulmonary  veins.  The  total 
pulmonary  resistance  is  governed  by  the  degree  of  lung  expansion, 
the  effect  of  negative  pressure  on  the  extrapulmonary  vessels,  vaso- 
motor variations,  and  altered  vis  a  fronte  caused  by  impaired  action 
of  the  left  heart.  Cloetta  has  shown  that  as  the  lungs  enlarge  a 
moderate  distention  diminishes  the  resistance,  but  an  extreme 
distention  augments  it. 

Traube-Herring  Waves. — These  were  first  noted  by  Traube.^  He 
observed  that  in  a  curarized  animal  with  artificial  respiration  if 
the  respiration  was  suspended,  the  aortic  pressure  rose  and  remained 
high  for  two  or  three  minutes,  and  that  during  that  time,  without 
any  movements  of  the  animal  or  any  respiratory  movement,  the 
arterial  pressure  showed  slow  waves,  about  seven  per  minute,  that 
might  have  an  amplitude  of  40  mm.  of  mercury.  The  cardiac  rate 
remained  unaltered.   After  two  or  three  minutes  the  arterial  pressure 

1  Central  f.  d.  med.  Wissensch.,  1865,  iii,  881. 


44  PHYSIOLOGY  OF  BLOOD-PRESSURE 

began  to  fall  and  from  this  moment  these  waves  ceased,  or  at  most 
a  few  feeble  ones  were  observed.  If,  now,  artificial  respiration  were 
resumed^  these  slow  waves,  perhaps  only  two  per  minute,  might  again 
for  a  while  be  observed,  the  waves  due  to  the  artificial  respiration 
and  to  the  cardiac  cycles  being  superimposed  upon  them.  He 
considered  these  waves  the  result  of  the  stimulus  of  CO2  upon  the 
vasoconstrictor  centre,  and  succeeded  in  producing  them  by  main- 
taining respiration  with  an  atmosphere  containing  20  per  cent,  of 
CO2.    The  tracing  in  Fig.  6  illustrates  these  oscillations. 

Intrapericardial  Pressure. — If  a  cannula  be  introduced  into  the  peri- 
cardium of  an  animal,  the  pericardium  ligated  around  the  cannula 
and  normal  saline  introduced  in  such  a  way  that  its  pressure  may 
be  measured  and  controlled,  it  will  be  found  that  a  very  slight 
positive  intrapericardial  pressure  will  cause  a  fall  of  aortic  blood- 
pressure  with  a  diminished  cardiac  output.  When  the  pressure 
rises  to  even  so  low  a  figure  as  8  to  10  mm.  Hg.  the  cardiac  output 
becomes  practically  nil  and  there  is  a  rapid  extreme  fall  of  pressure 
due  to  occlusion  of  the  great  veins  supplying  the  auricles,  by  an 
intrapericardial  pressure  exceeding  the  venous  pressure. 

Intra-abdominal  Pressure. — If,  while  recording  the  carotid  or 
femoral  pressure  of  a  dog,  pressure  be  exerted  over  the  abdomen 
with  the  hand  or  in  any  other  way,  the  arterial  blood-pressure  will 
be  seen  to  rise  10  to  20  mm.  Hg.,  and  to  remain  at  a  somewhat 
elevated  level  while  the  pressure  is  maintained.  This  is  due  to 
the  fact  that,  as  already  noted,  the  splanchnic  vessels  constitute 
the  great  reservoir  for  the  blood.  Increase  of  intra-abdominal 
pressure  tends  to  empty  these  vessels  onward  into  the  right  auricle, 
and  hence  by  increasing  the  venous  supply  to  the  heart  to  increase 
the  cardiac  output.  At  the  same  time  the  additional  pressure 
increases  somewhat  the  resistance  offered  to  flow  through  the 
mesenteric  capillaries,  and  hence  resistance  of  the  most  important 
vascular  area  from  the  stand-point  of  the  determination  of  blood- 
pressure.  By  both  means  increased  intra-abdominal  blood-pressure 
leads  to  increased  arterial  blood-pressure.  Conversely,  relaxation 
of  ithe  abdominal  walls  favors  low  arterial  blood-pressure  with 
stasis  of  the  blood  in  the  splanchnic  area,  but  this  tendency  may 
be  entirely  counter-balanced  by  adequate  vasomotor  tone  in  these 
vessels. 

Burton-Opitz^  has  shown  that  an  increased  intra-abdominal 
pressure  up  to  20  to  30  mm.  Hg.  causes  an  increased  blood  flow 

'  The  Carotid  Blood  Flow  in  Relation  to  the  Intra-abdominal  Pressure,  Am. 
Jour.  Physiol.,  1914,  xxxvi,  64. 


BLOOD-PRESSURE  THROUGHOUT  THE   VASCULAR   TREE    45 

and  blood-pressure  in  the  carotid  arteries  and  external  jugular 
veins  and  also  an  increased  blood-pressure  in  the  femoral  artery. 
There  is  evidently  brought  about,  therefore,  a  shifting  of  the  blood 
from  the  splanchnic  to  the  peripheral  circulation  and  especially 
to  the  head  under  such  conditions. 

Extremely  high  intra-abdominal  pressure,  as  from  a  very  large 
ascites,  may  interfere  with  the  return  of  blood  to  the  heart,  and 
lower  arterial  blood-pressure. 

Hepatic  Circulation. — Burton  Opitz  has  studied  the  circulation 
through  the  liver  and  its  vasomotor  control.  He  finds  that  in  a 
15-kilo  dog  the  liver  receives  a  flow  of  blood  of  about  420  c.c.  per 
minute;  therefore  an  amount  of  blood  equal  to  the  entire  amount 
in  the  body  traverses  the  liver  every  three  minutes.  Studies 
by  means  of  the  Strohmiihr  showed  that  two-thirds  of  this  blood 
is  derived  from  the  portal  system  and  one-third  from  the  hepatic 
artery.  The  portal  pressure  was  about  10  mm.  Hg.  Stimulation 
of  the  splanchnic  nerve  led  first  to  an  increase  of  the  portal  flow  and 
a  rise  of  the  pressure  in  the  portal  vein  soon  followed  by  a  diminished 
portal  flow  and  fall  in  the  portal  pressure.  This,  however,  was 
compensated  for  by  an  increased  flow  from  the  hepatic  artery 
resulting  from  the  increased  aortic  pressure  that  follows  splanchnic 
stimulation. 

Blood-pressure  and  Intracranial  Pressure. — The  brain  is  enclosed 
in  a  bony  encasement  and  is,  so  to  speak,  floating  in  the  cerebro- 
spinal fluid.  This  fluid  fills  the  subarachnoid  space,  the  ventricles 
and  their  communicating  passages;  all  these  spaces  are  normally 
in  free  communication. 

Evidence  indicates  that  the  pressure  of  the  cerebrospinal  fluid 
is  always  equal  to  the  venous  pressure  in  the  brain  sinuses.  This 
pressure  may  vary  from  0  in  the  upright  position  (Hill)^  to  50  to 
60  mm.  Hg.  in  the  convulsions  of  strychnine  poisoning,  or  even 
more  in  cases  of  brain  tumor.  If  the  intracranial  pressure  exceeds 
the  carotid  pressure  the  circulation  through  the  brain  becomes 
entirely  checked,  due  to  compression  of  the  capillaries.  Complete 
occlusion  of  the  larger  cerebral  arteries  occurs,  however,  only  when 
the  intracranial  pressure  is  raised  (experimentally)  to  about  150 
mm.  Hg.  above  the  carotid  pressure  (Eyster,  Burrows  and  Essick).- 
The  cerebral  anemia  produced  by  a  rise  of  intracranial  pressure 
to  the  level  of  the  carotid  pressure  was  shown  by  Gushing^  to  produce 

1  The  Physiology  and  Pathology  of  the  Cerebral  Circulation,  London,  1896;  Proc. 
Royal  Soc,  1894,  Iv,  52. 

2  Jour.  Exper.  Med.,  1909,  xi,'489. 

'  Mitteil.  aus  den  Grenz.  der  Med.  u.  Chir.,  1902,  ix,  791;  Am.  Jour.  Med.  So., 
1903, exxv, 1017. 


46      ,  PHYSIOLOGY  OF  BLOOD-PRESSURE 

two  reflex  effects:  (1)  stimulation  of  the  vagus  with  slowing  of 
the  cardiac  action;  (2)  stimulation  of  the  vasomotor  centre,  with 
general  vasoconstriction  and  rise  of  carotid  pressure  to  the  level 
of  the  intracranial  pressure,  and  in  consequence  the  reestablishment 
of  the  cerebral  circulation.  If  the  increase  of  intracranial  pressure 
be  very  gradual  the  vagus  excitation  may  not  be  elicited.  Gushing 
likewise  studied  the  effects  of  localized  pressure  upon  portions  of 
the  brain  and  obtained  various  results  dependent  upon  the  location 
selected.  Pressure  upon  the  medullary  centres  acts  as  does  increase 
in  general  intracranial  tension.  The  elevated  blood-pressure  asso- 
ciated with  intracranial  pressure  secondary  to  neoplasms  of  the 
brain  is  to  be  considered  a  compensatory  and  beneficent  process 
for  the  maintenance  of  blood  flow  through  the  vital  centres.  If  this 
compensatory  rise  does  not  occur,  absolute  cerebral  anemia  results. 
The  time  that  different  portions  of  the  brain  can  endure  anemia 
and  recover  varies  greatly.  Experiments  by  Crile  and  Dolley 
showed  that  the  central  nervous  system  of  young  animals  endures 
anemia  better  than  that  of  older  ones.  Those  parts  of  the  brain 
which  preside  over  conscious  life,  the  higher  psychic  centres,  were 
in  no  instances  resuscitated  after  total  anemia  of  eight  minutes, 
but  always  after  only  four  minutes.  The  vasomotor  centre  was 
frequently  resuscitated  after  fifteen  minutes,  occasionally  after 
eighteen,  once  after  twenty,  and  once  in  a  puppy  after  thirty 
minutes.  The  respiratory  centre  was  more  resistant,  moderate 
reaction  being  obtained  after  as  much  as  forty  minutes  of  total 
anemia.  We  may  say,  therefore,  that  reduction  of  arterial  pressure 
results  in  lessened  blood  supply  and,  as  a  rule,  diminished  activity 
within  the  brain;  that  if  this  reduction  be  great  enough,  complete 
anemia  of  the  brain  results  with  cessation  of  its  activities,  and 
unless  the  blood  supply  be  promptly  restored,  a  permanent  cessa- 
tion ;  also  that  the  arterial  blood-pressure,  so  far  as  it  concerns  the 
brain,  must  be  considered  with  relation  not  to  the  atmospheric, 
but  to  the  intracranial  pressure,  hence  a  rise  of  intracranial  pressure 
is  equivalent  to  a  fall  of  blood-pressure,  and  vice  versa. 

Blood-pressure  and  Intra-ocular  Pressure.— The  chambers  of  the 
eyeball  are  filled  with  fluids  which  distend  the  eyeball  and  maintain 
a  pressure  in  these  cavities  normally  of  about  20  to  30  mm.  Hg.  in 
man.  The  intra-ocular  pressure  is  measured  by  one  of  two  methods : 
(1)  Ophthalmomanometry,  in  which  the  pressure  is  measured 
directly  by  introducing  a  hollow  needle  into  one  of  the  chambers, 
preferably  the  anterior,  and  connecting  it  with  a  suitable  manometer 
or  system  of  manometers;  (2)  ophthalmotonometry,  in  which  the 


BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR  TREE    47 

degree  of  internal  pressure  is  estimated  by  the  amount  of  resistance 
to  deformation  offered  by  the  walls  of  the  eyeball.  Obviously 
only  the  second  method  is,  as  a  rule,  applicable  to  man ;  it  has,  how- 
ever, certain  fallacies  and  objections  among  which  are  the  error 
introduced  by  the  inherent  rigidity  of  the  ocular  walls,  that  due  to 
the  increase  of  intra-ocular  pressure  caused  by  the  distortion  of  the 
eyeball,  as  well  as  the  dangers  and  discomforts  of  the  application  of 
the  instrument.  These  errors  in  the  latest  instruments  are,  however, 
largely  eliminated.  The  pressures  in  the  aqueous  and  vitreous 
chambers  of  the  eye  are  practically  identical,  not  differing  by  more 
than  1  mm.  Hg.  The  distensibility  of  the  walls  of  the  eyeball  is 
so  slight  that  under  ordinary  conditions  any  increase  in  the  fluids 
within  the  eyeball,  either  in  one  of  the  chambers  or  in  vessels  of 
the  choroid,  must  cause  an  increase  in  the  intra-ocular  pressure. 
This  fact  leads  to  almost  complete  suppression  of  the  visible  pulsa- 
tion of  the  retinal  arteries.  Likewise  the  pressure  in  the  blood- 
vessels, including  capillaries  and  veins,  can  never  fall  below  the 
intra-ocular  pressure  without  collapse  of  these  vessels  and  cessation 
of  the  flow  through  them.  Since  the  outflow  from  the  veins  of 
the  eye  is  usually  a  steady  stream  the  venous  pressure  must  be 
normally  equal  to  the  intra-ocular  pressure.  The  capillary  pressure 
within  the  eye  is  supposed  by  Parsons^  to  be  40  to  50  mm.  Hg., 
and  that  in  the  veins  to  equal  the  intra-ocular  pressure. 

The  fluids  distending  the  eyeball  circulate  along  one  of  two 
courses:  (1)  That  of  the  blood  entering  the  ciliary  arteries  and 
leaving  by  the  scleral  veins,  the  vense  vorticosse;  (2)  that  of  the 
lymph  fluids  filling  the  vitreous  and  aqueous  chambers,  entering 
the  vitreous  chamber  from  the  vessels  of  the  ciliary  processes,  passing 
into  the  aqueous  chamber  and  leaving  at  the  filtration  angle  by 
the  spaces  of  Fontana  for  the  canal  of  Schlemm  and  thence  into 
the  scleral  veins.  As  long  as  the  intra-ocular  tension  is  to  remain 
constant  the  combined  inflow  along  these  two  courses  must  equal 
the  combined  outflow.  All  evidence  indicates  that  the  rate  of 
secretion  of  lymph  into  the  posterior  chamber  is  proportional  to 
intracapillary  pressure  in  the  eyeball.  Therefore  an  increase  of 
intracapillary  pressure  not  only  tends  to  increase  intra-ocular 
tension  directly,  but  also  indirectly  by  increasing  Ijinph  production. 
Rapid  changes  in  intra-ocular  pressure  are  probably  due,  as  a  rule, 
to  changes  in  intravascular  pressure  and  volume;  slower  changes 
may  be  due  to  alterations  in  the  rate  of  lymph  formation  or  removal. 

1  Diseases  of  the  Eye,  Philadelphia,  1912. 


48  .     PHYSIOLOGY  OF  BLOOD-PRESSURE 

It  is  possible,  as  shown  by  ophthalmoscopic  examination,  to  have 
distention  of  the  retinal  arteries  and  veins  with  normal  intra- 
ocular tension  due  to  compensatory  adjustment  in  the  quantity 
of  lymph.  As  a  rule,  however,  the  intra-ocular  pressure  is  closely 
related  to  the  circulatory  conditions  in  the  eyeball. 

The  Intra-ocular  Pressure  Rises. — 1.  With  increase  in  the  arterial 
pressure  in  the  arteries  supplying  the  eyes,  as  from  compression  of 
the  thoracic  aorta,  stimulation  of  the  vasomotor  centre  or  of  the 
splanchnic  nerves,  asphyxia,  general  effects  of  adrenalin,  injection 
of  normal  saline,  etc.  At  times  the  intra-ocular  tension  may  be 
shown  to  vary  with  the  respiratory  or  the  Traube-Herring  blood- 
pressure  waves. 

2.  With  local  dilatation  of  the  arterioles  of  the  eyes.  The  exist- 
ence of  vasomotor  fibers  for  these  vessels  has  not  as  yet  been  satis- 
factorily demonstrated,  since  changes  in  the  intra-ocular  pressure 
following  stimulation  or  section  of  various  nerves  may  in  all  cases 
be  attributed  either  to  effects  upon  the  general  blood-pressure,  or 
to  stimulation  of  the  extra-ocular  muscles  (v.  infra). 

3.  From  venous  obstruction.  Rise  in  general  venous  pressure 
is  probably  never  sufficient  to  counter-balance  the  contrary  effects 
of  the  associated  fall  of  arterial  pressure.  Moreover,  the  relatively 
high  venous  pressure  within  the  eyeball  renders  considerable  changes 
in  general  venous  pressure  of  but  slight  moment.  On  the  other 
hand,  local  venous  obstruction,  as  by  ligation  of  the  vense  vorticosse, 
leads  to  marked  rise  of  intra-ocular  pressure  (up  to  90  mm.  Hg.), 
(Adamiik,  Leber,  Koster,  Gzn)  with  increased  transudation  of 
highly  albuminous  lymph.  There  follows  a  slow  return  to  normal 
pressure  in  the  course  of  a  few  weeks. 

4.  From  increased  lymph  formation  from  any  of  the  above- 
named  causes  of  increased  capillary  pressure. 

5.  From  decreased  lymph  drainage  either  from  venous  obstruc- 
tion or  from  obstruction  of  the  filtration  angle,  as  with  pupillary 
dilatation  in  glaucoma. 

J" he  intra-ocular  tension  falls  as  the  result  of  the  reverse  of  the 
abbve-mentioned  factors : 

1.  From  fall  in  blood-pressure  in  the  arteries  supplying  the  eyes. 

2.  From  local  arteriolar  constriction  such  as  may  be  obtained 
from  adrenalin  (Parsons)  or  nicotin  (Henderson  and  Starling) 
by  injection  into  the  carotid,  their  local  effects  preceding  their 
general  systemic  effects. 

3.  From  diminished  hinph  formation  secondary  to  any  of  the 
above-named  causes  of  reduced  blood-pressure. 


BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR  TREE    49 

4.  From  improved  lymph  drainage,  as  by  freeing  of  the  filtration 
angle  by  pupillary  contraction. 

The  Relation  of  Blood-pressure  to  Secretion. — The  activity  of  all 
glands  is  associated  with  increased  blood  flow  through  the  gland. 
This  increased  blood  flow  that  is  associated  with  glandular  activity 
was  early  noted  in  connection  with  chorda  tympani  stimulation 
and  the  resultant  abundant  flow  of  saliva.  It  was  naturally  sug- 
gested that  the  abundant  flow  of  saliva  might  be  entirely  the  result 
of  the  increased  circulation  and  capillary  blood-pressure  in  the 
gland,  due  to  the  vasodilator  fibers  in  the  chorda  tympani.  Ludwig^ 
showed,  however,  by  measuring  the  pressure  in  the  salivary  duct 
by  means  of  a  manometer  that  following  stimulation  of  the  chorda 
tympani  the  pressure  in  the  salivary  duct  might  exceed  the  blood- 
pressure.  Moreover,  if  blood-pressure  be  shut  off  from  the  gland, 
stimulation  of  the  chorda  still  gives  secretion  for  a  short  time, 
whereas  if  atropin  be  injected  into  the  gland,  chorda  stimulation 
causes  dilatation  of  the  vessels  and  increased  blood  flow  but  no 
secretion.  Hydrochlorate  of  quinine  injected  into  the  gland  causes 
vascular  dilatation  but  no  secretion.  Therefore,  while  an  abundant 
blood  flow  is  essential  for  the  proper  functioning  of  actively  secret- 
ing glands,  it  is  not  in  itself  the  cause  of  the  increased  secretion. 

Effects  of  Exercise  on  Blood-pressure. — The  effect  of  exercise  on 
blood-pressure  has  been  studied  by  many.  One  of  the  first  inves- 
tigations was  that  of  Marey^  who  measured  the  systolic  pressure 
in  the  carotid  of  a  horse  before  and  after  a  run  of  ten  minutes  and 
noted  a  fall  from  108  mm.  Hg.  before  to  102  after.  Kaufmann^ 
likewise  found  after  prolonged  exertion  in  horses  a  fall  of  pressure. 
Almost  uniformly,  however,  the  other  observers,  investigating  for 
the  most  part  the  dog  and  man,  have  noted  a  rise  in  pressure  after 
exercise.  Tangl  and  Zunst*  measured  the  maximal  and  minimal 
carotid  pressures  in  the  dog  and  from  them  calculated  the  approxi- 
mate mean  pressure.  Aftdr  having  the  animal  run  up  steps  they 
found  a  rise  of  from  6  to  23  mm.  Hg.  After  very  severe  exertion 
the  elevation  was  extreme,  amounting  to  120  mm.  Hg.  Experiment- 
ing upon  himself,  von  Basch^  had,  in  1887,  noted  after  a  quick  ten- 
minute  climb  up  a  hill  a  rise  from  125  mm.  Hg.  to  180  mm.  Von 
Maximowisch  and  Rieder^  studied  the  effect  on  27  individuals  of 
2500  kg.  of  work  performed  on  a  Gartner  ergostat  in  three  to  five 
minutes  and  they  obtained  in  21  individuals  a  rise;  in  5  no  change; 

»  L.  Hill  and  W.  Flack:   Proc.  Royal  Soc,  London,  1912,  S.  B.,  Ixxxv,  312. 
«  Traveaux  du  Laboratoire,  1876.  *  Arch.  f.  d.  ges.  Physiol.,  1892,  liii. 

*  Ibid.,  1898,  Ixx,  544.  » Berl.  klin.  Wchnschr.,  1887,  xxiv,  206. 

« Deutsch.  Arch.  f.  klin.  Med.,  1890,  xlvi. 
4 


50  PHYSIOLOGY  OF  BLOOD-PRESSURE 

and  in  1  a  fall  of  systolic  pressure;  the  greatest  rise  was  50  mm. 
Ilg.;  the  one  fall  was  20  mm.  Oertel^  in  8  individuals  after  moun- 
tain climbing  noted  a  rise  in  all  varying  from  3  to  43  mm.,  the 
average  being  17  mm.  A  rise  after  exertion  has  likewise  been 
noted  by  Zadek,^  Friedmann, '  Grebener^  and  Griinbaun/  Edge- 
comb  and  Bain,  Eichberg,^  Russell,  Williamson,^  Routhier  and 
Boussaguet,^  and  Graupner.^  Moritz^  obtained  somewhat  similar 
results,  Bruck^°  has  noted  in  man  with  the  Riva-Rocci  and  with 
the  Hiirthle  apparatus  an  immediate  rise  upon  commencing  sudden 
severe  exertion,  up  to  30  or  40  mm.  Hg.,  followed  after  a  few  pulse 
beats  by  a  fall  to  subnormal  and  then  a  prompt  return  to  from  18 
to  38  mm.  above  normal.  This  brief  primary  rise  he  attributes 
to  increased  intrathoracic  pressure.  He  measured  the  intrathoracic 
pressure  by  introducing  a  rubber  bag  into  the  esophagus  and  found 
it  at  the  time  of  the  primary  rise  of  blood-pressure  to  be  from  50 
to  130  mm.  Hg.  This  pressure  forces  the  thoracic  blood  on  into 
the  left  ventricle  and  hence  into  the  aorta  with  rise  of  pressure. 
The  following  brief  fall  he  attributes  to  interference  with  the 
entrance  of  more  blood  into  the  thorax. 

Erlanger  and  Hooker,^'^  making  graphic  records  of  maximal  and 
minimal  pressure  in  man,  find  that  very  moderate  muscular  exer- 
tion as,  for  example,  walking,  may  diminish  the  minimal  pressure 
while  increasing  the  pulse  pressure,  pulse  rate,  and  presumably  the 
blood  flow.  More  severe  muscular  exertion  increases  these  and  in 
addition  the  minunal  pressure. 

Probably  the  chief  cause  of  the  increased  pressure  accompanying 
exercise  is  increased  cardiac  activity.  A  factor  in  influencing 
greatly  the  rise  of  pressure  accompanying  exertion  is  the  degree 
of  mental  effort  involved.  An  unusual  form  of  exertion  or  one 
requiring  close  attention  causes  much  more  increase  of  pressure 
than  the  same  amount  of  work  performed  in  the  course  of  habitual 
action.  Thus,  Karrenstein^^  found  in  172  observations  on  72  soldiers 
making  a  5.7  km.  march  in  seventy  minutes,  that  39.5  per  cent, 
showed  a  rise,  16.3  per  cent,  no  change,  and  44.2  per  cent,  a  fall; 
the  average  pressure  before  and  after  the  march  was  unchanged. 

'  Therapie  d.  kreislausfstorungen,  v.  Ziemssen's  Handbuch  d.  allg.  Therapie,  vol.  iv. 

2  Ztschr.  f.  klin.  Med.,  1881,  ii,  509.  '  Wien.  med.  Jahrb.,  1882,  p.  197. 

*  Wien.  med.  Presse,  1899,  xl,  49. 

'Jour.  Am.  Med.  Assn.,  1908,  li,  1000. 

« British  Med.  Jour.,  1909,  i,  530. 

'  Compt.  rend  de  la  Soc.  de  biol.,  Paris,  1910,  Ixviii,  1037. 

8  Deutsch.  med.  Wchnsehr.,  1906.  xxxii,  1028. 

»  Deutsch.  Arch.  f.  klin.  Med.,  1903,  Ixxv-ii,  339.  >»  Ibid.,  1907,  xvi,  171. 

"  Johns  Hopkins  Hospital  Reports,  1904,  xii,  53. 

»  Ztschr.  f.  klin.  Med.,  Berlin,  1903,  1,  322  (bibliography). 


BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR  TREE    51 

Of  39  observations  on  25  soldiers  following  a  two  to  three  hours' 
march,  12.8  per  cent,  showed  a  rise  and  69.2  per  cent,  a  fall,  the 
average  being  lowered  from  106.1  to  98.8  mm.  Hg.  In  these  cases 
little  if  any  mental  effort  was  involved.  The  effect  of  mental 
effort  has  been  shown  by  Putermann,^  who  studied  with  the  Gartner 
tonometer  the  blood-pressure  of  43  boys  immediately  before  and 
after  a  school  examination.  A  rise  occurred  immediately  before 
the  examination  in  37,  a  fall  in  4.  The  rise  was  usually  10  to  20 
mm.  Hg.,  but  one  rise  of  50  mm.  was  noted.  Any  excitement  may 
lead  to  a  similar  rise;  indeed,  the  mere  taking  of  the  blood-pressure 
in  a  susceptible  subject.  This  psychic  rise  affects  the  systolic 
pressure  more  than  the  diastolic.  The  acceleration  of  the  pulse 
during  exercise  is  due  to  depression  of  the  cardio-inhibitory  centre. 
It  seems  that  the  secondary  fall  of  pressure  due  to  peripheral  vaso- 
dilatation is  the  result  of  depression  of  the  vasoconstrictor  centre 
and  not  of  active  vasodilatation,  and  that  a  similar  depression  of 
the  respiratory  centre  may  occur  from  cortical  inhibition.^ 

Effects  of  Posture. — It  has  already  been  noted  that  the  chief 
reservoir  for  the  blood  is  the  splanchnic  area  which  of  itself  can 
contain  all  the  blood  of  the  body.  Normally,  an  adequate  return 
of  blood  from  this  reservoir  to  the  right  auricle  is  secured  by  means 
of  the  vasomotor  tone  of  the  splanchnic  vessels.  In  the  upright 
posture  this  return  must  occur  against  the  force  of  gravity.  In 
the  recumbent  posture,  the  antagonistic  action  of  gravity  is  removed. 
Normally  in  man  the  reflex  regulation  of  the  splanchnic  vasomotor 
tone  is  such  that  change  from  the  recumbent  to  the  upright  posture 
is  immediately  compensated  by  an  increased  splanchnic  vasomotor 
tone,  and  the  aortic  blood-pressure  is  maintained  almost  unaltered 
or  there  may  be  noted  even  a  considerable  rise  of  the  diastolic 
pressure.  In  subjects  with  defective  vasomotor  compensation,  how- 
ever, there  may  occur  a  fall  of  the  aortic  blood-pressure  upon 
transition  from  the  recumbent  to  the  upright  posture,  and  this  may 
be  of  some  diagnostic  value.  The  common  treatment  of  syncope 
by  placing  the  patient  recumbent  has  for  its  basis  the  effort  to  make 
gravity  assist  instead  of  resist  the  action  of  the  splanchnic  vaso- 
motor tone,  which  in  this  condition  as  in  surgical  shock  and  collapse, 
is  inadequate.  Change  from  sitting  posture  to  standing  causes, 
normally,  according  to  most  observers,  a  rise  of  from  5  to  15  mm. 
Hg.  of  systolic  brachial  pressure.    Erlanger  and  Hooker,  studying 

» Wien.  med.  Wchnschr.,  1904,  liv,  265. 

*  Martin  and  Gruber:  The  Influence  of  Muscular  Exercise  on  the  Activity  of  Bulbar 
Centers,  Am.  Jour.  Physiol.,  1913,  xxxii,  315. 


52  PHYSIOLOGY  OF  BLOOD-PRESSURE 

the  minimal  and  pulse-pressures,  found  usually  but  not  constantly 
on  assuming  the  standing  posture  a  rise  in  the  minimal  pressure, 
but  a  slight  fall  in  pulse-pressure.  Karrenstein^  noted  a  little  lower 
brachial  systolic  pressure  in  recumbent  than  in  sitting  posture. 
On  stooping  he  found  in  90.8  pfer  cent,  of  153  cases  a  rise  of  from 
1  to  45  mm.  (average  10.8).  The  effect  of  posture  upon  vessels 
not  at  the  level  of  the  heart  has  been  considered  (p.  24).  Barach 
and  Marks^  upon  changing  the  posture  from  the  upright  to  the 
recumbent  in  an  entirely  passive  manner  in  48  subjects  between 
fifteen  and  thirty  years  of  age,  have  observed  the  following  effects 
which  differ  from  those  of  earlier  observers:  In  changing  from 
the  erect  to  the  horizontal  the  maximal  pressure  was  usually 
increased,  the  cases  varying  from  an  increase  of  28  mm.  Hg.  to  a 
decrease  of  20  mm.  Hg.  The  minimal  pressure  was  almost  always 
diminished,  varying  from  an  increase  of  4  mm.  Hg.  to  a  decrease 
of  44  mm.  Hg.  When  the  erect  posture  is  resumed  after  five  min- 
utes, the  maximal  pressure  almost  invariably  falls  and  the  minimal 
almost  invariably  rises.  In  the  falling  of  the  maximal  pressure 
when  the  erect  posture  is  resumed,  it  will  nearly  always  fall  con- 
siderably below  the  previous  height  of  the  first  reading,  while  the 
minimal  pressure  may  be  higher  or  lower  than  the  first  reading 
with  almost  equal  frequency.  The  pulse-pressure  in  its  variations 
follows  closely  the  maximal  pressure.  Persons  with  poor  muscular 
development  show  a  tendency  to  reversal  of  the  pressure  curve. 

Effect  of  Feeding. — After  eating  a  full  meal  Karrenstein*  noted 
usually  a  rise  of  systolic  pressure  of  10  to  20  mm.  Erlanger  and 
Hooker*  obtained  variable  effects  upon  minimal  pressure,  but  a 
constant  increase  of  pulse-pressure.  These  authors  noted  a  slow 
increase  of  pulse-pressure  throughout  the  day,  it  being  smallest 
in  the  early  morning  before  rising.  They  found  immersion  of  the 
body  in  warm  water  to  increase  minimal  pressure,  pulse-pressure 
and  pulse  rate;  in  cold  water  to  increase  minimal  pressure,  but  to 
decrease  pulse-pressure  and  rate.  Immediately  after  the  ingestion 
of  food  the  systolic  pressure  rises  (about  8  mm.  Hg.  in  healthy 
young  adults),  then  gradually  falls  until  the  beginning  of  the  next 
meal.  The  diastolic  pressure  is  much  less  and  variably*  affected 
by  feeding.  Associated  we  find  an  increased  pulse  rate  and  pulse- 
pressure.* 

»  Loc.  cit.  '  Arch.  Int.  Med.,  1913,  xi,  485. 

'  Loc.  cit.  *  Loc.  cit. 

'Weysse,  H.  W.,  and  Brenton,  R.  L.:  Diurnal  Variations  in  Arterial  Blood- 
pressTire,  Am.  Jour.  Physiol.,   1915,  xxxvii,  330. 


BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR  TREE    53 

Sleep. — Tarchanoff^  noted  a  fall  of  aortic  pressure  in  young 
dogs  of  20  to  50  mm.  Hg.  during  the  early  stages  of  sleep.  Leonard 
Hill,2  Brush  and  Fayerweather,^  Howell  and  Brooks,  and  Carroll* 
have  studied  the  phenomenon  in  man  and  note  the  greatest  fall 
one  or  two  hours  after  commencement  of  sleep;  this  may  amount 
to  20  mm.  Then  begins  a  gradual  rise  continuing  to  the  maximum, 
usually  reached  about  5  p.m.  the  following  day.  If  sleep  is  dis- 
turbed the  usual  drop  is  less  profound.  In  day  sleepers  it  is  the  day 
pressure  which  is  lower  than  the  night.  The  minimal  blood-pressure 
is  according  to  Weysse  and  Lutz  very  uniform  throughout  the  day, 
but  with  a  tendency  to  a  slight  lowering  as  the  day  progresses. 

Altitude. — The  study  of  the  effects  of  altitude  on  blood-pressure 
has  been  approached  in  two  ways:  (1)  By  the  study  of  the  blood- 
pressure  of  individuals  remaining  for  longer  or  shorter  periods  at 
various  altitudes,  and  (2)  by  the  use  of  the  pneumatic  chamber  to 
change  the  atmospheric  pressure. 

The  blood-pressure  may  either  be  measured  as  so  many  milli- 
meters of  mercury  above  the  surrounding  atmospheric  pressure, 
or  the  absolute  pressure  of  the  blood  may  be  measured.  It  may  be 
stated  at  once  that  changes  in  atmospheric  pressure  are  associated 
with  approximately  equal  changes  of  the  absolute  blood-pressure 
in  the  same  direction.  Thus,  if  at  760  mm.  atmospheric  pressure 
(ordinary  atmospheric  pressure  at  sea  level)  the  absolute  systolic 
blood-pressure  is  895  mm.  (135  mm.  above  atmospheric  pressure), 
then  if  the  atmospheric  pressure  be  reduced  to  460  mm.  the  absolute 
systolic  pressure  will  be  reduced  to  about  595  mm.  Since  all  the 
manometers  ordinarily  used  measure  the  elevation  of  the  blood- 
pressure  above  the  surrounding  atmospheric  pressure,  it  is  this 
difference  of  pressure  that  is  ordinarily  discussed.  Moreover,  it  is 
this  difference  of  pressure  and  not  the  absolute  pressure  which  is 
the  measure  of  the  functional  activities  of  the  circulatory  system. 
It  is  to  be  understood,  therefore,  that  whenever  pressure  is  here 
referred  to  it  is  the  pressure  in  excess  of  the  surrounding  atmospheric 
pressure,  that  is,  the  relative  blood-pressure,  that  is  meant. 

The  first  to  study  the  effects  of  changes  of  atmospheric  pressure 
upon  the  blood-pressure  was  Paul  Bert.^  Upon  lowering  the 
atmospheric  pressure  he  obtained  a  slight  diminution  of  the  relative 
blood-pressure. 

I  Arch.  Ital.  de  Biol.,  1894,  xxi,  318. 

*  Lancet,  1898,  i,  282.  »  Am.  Jour.  Physiol.,  1901,  v,  199. 

*  Tr.  Assn.  Am.  Phys.,  Philadelphia,  1912,  xxvii,  8. 
'  La  Pressure  barometrique,  Paris,  1878. 


54  PHYSIOLOGY  OF  BLOOD-PRESSURE 

Lazarus  and  Schirmunski^  in  1884  studied  a  man  in  the  pneumatic 
chamber  with  the  following  results: 


ipherio  pressure. 

Relative  systolic  blood-pressure. 

mm.  Hg. 

mm.  Hg. 

760 

'                                   135 

670 

135 

440 

132"!   Subjective 
1  lOj       dyspnea. 

380 

460 

118 

660 

135 

760 

130 

Camus^  with  rabbits  in  a  pneumatic  chamber  reduced  the  pressure 
from  760  to  200  mm.  with,  in  some  animals,  little  or  no  fall  of  the 
relative  blood-pressure,  but  with  other  rabbits  on  reaching  about 
250  mm.  atmospheric  pressure  the  relative  blood-pressure  showed  a 
marked  fall. 

Mosso,^  with  a  dog  in  a  pneumatic  cabinet,  with  reduction  of 
atmospheric  pressure  to  228  mm.  Hg.,  obtained  a  slight  fall  of 
relative  blood-pressure.  On  the  other  hand,  Frankel  and  Gepperf 
and  also  Dietrick  with  lowered  atmospheric  pressure  obtained  a 
slight  rise  of  relative  blood-pressure,  while  G.  Liebig*  obtained  a 
rise  in  2  men,  but  in  2  others  a  fall. 

The  approximate  relation  of  atmospheric  pressure  to  altitude 
is  shown  in  the  following  table  from  Camus:" 

Atmospheric  pressure,  Altitude,  Altitude, 

mm.  Hg.  meters.  feet. 

760 0  0 

660 1,148  3,760 

560 2,370  7,760 

460 4,022  13,200 

360 5,945  19,470 

260 8,600  28,180 

200 11,000  36,040 

Studies  of  individuals  actually  at  various  altitudes  are  not 
numerous. 

Schneider  and  Hedblom^  studied  the  effect  on  a  series  of  individ- 
uals passing  from  1700  elevation  to  GOOO  feet  and  again  later  from 
6000  to  14,109  feet.  In  passing  from  1700  to  GOOO  feet  they  observed 
falls  of  relative  pressure  of  from  3  to  7  mm.  Hg.,  with  no  changes 

'  Ztschr.  f.  klin.  Med.  1884,  vii,  299. 

*  Jour,  de  physiol.  et  de  pathol.  g6n.,  Paris,  1903,  v,  643. 
»  Arch.  Ital.  de  Biol.,  1909,  xliii. 

*  Ueber  die  Wirkungen  der  verdunnte  Luft,  Berlin,  1883,  p.  65. 

'  Sitzungsberichte  d.  gesellsch.  f.  Morphol.  u.  Physiol.,  Munich,  1896,  xii,  37. 

'  Loc.  cit. 

'Am.  Jour.  Physiol.,  1908-9,  xxiii,  90  (bibHography). 


BLOOD-PRESSURE  THROUGHOUT  THE  VASCULAR  TREE     55 

in  the  average  diastolic  pressure.  In  passing  from  6000  to  14,109 
feet  they  found  an  average  fall  of  both  systolic  and  diastolic  pressures 
of  7  mm.  Hg.,  and  an  average  rise  of  pulse  rate  of  26  beats  per 
minute.  The  effect  upon  the  systolic  pressure  was  more  constant 
than  that  upon  the  diastolic.  The  effect  of  the  altered  altitude  was 
most  marked  immediately  following  the  arrival  at  the  new  level, 
and  those  individuals  showed  most  changes  who  were  most  affected 
subjectively  by  the  change  of  altitude.  Small  changes  of  elevation 
were  without  any  effect. 

Staehelin^  studied  blood-pressure  during  balloon  ascensions  to 
a  height  with  atmospheric  pressure  of  090  mm.  without  noting 
any  effect  on  either  systolic  or  diastolic  pressure.  Staubli^  noted 
at  St.  Moritz  (5800  feet)  no  constant  change  in  the  blood-pressure 
of  healthy  subjects. 

Clough^  has  recently  published  studies  of  the  effects  of  a  rapid 
descent  of  1700  feet  in  a  mine  shaft.  He  found  that  the  rapid  change 
in  altitude  either  up  or  down  frequently  caused  a  fall  of  systolic 
pressure  of  5  mm.  He  detected  no  significant  difference  between 
the  average  blood-pressure  of  individuals  living  at  the  altitude  of 
5000  feet  and  those  at  sea  level. 

Gardiner  and  Hoagland*  studied  individuals  living  for  a  year 
at  an  altitude  of  6000  feet  and  found  their  relative  pressures  only 
slightly  lower  than  those  observed  in  individuals  of  the  same  age 
at  sea  level.  They  studied  the  systolic  pressures  of  22  college  men 
going  by  train  from  a  level  of  6000  feet  to  14,109.  The  average 
relative  pressure  at  6000  feet  was  126  mm.  Hg.;  on  arrival  at  14,109 
feet,  121  mm.  Hg.;  three  and  a  half  hours  after  arrival,  118  mm.  Hg. 
Smith^  in  a  recent  study  has  concluded  that  an  altitude  of  6230 
feet  does  not  produce  any  consistent  alteration  of  blood-pressure 
in  either  normal  or  tuberculous  individuals. 

Schneider,  Cheley>  and  Sisco^  have  studied  the  effect  of  physical 
exertion  upon  the  blood-pressure  at  very  high  altitudes  (14,900  feet). 
While  the  arterial  blood-pressure  at  rest  was  found  to  be  unchanged 
or  a  trifle  lower  at  this  high  altitude,  the  effect  of  exertion  was  to 
induce  a  much  more  marked  rise  of  pressure  than  would  follow  the 
same  degree  of  exertion  at  lower  altitudes  or  at  sea  level.  This 
increased  reaction  to  exercise  was  most  conspicuous  during  the  first 
days  of  residence  in  the  high  altitude,  was  slightly  lessened  by 

'  Med.  Klin.,  1909,  v,  361. 

« Verhandl.  d.  Kong.  f.  inn.  Med.,  1910,  p.  695. 

'  Arch.  Int.  Med.,  1913,  xi,  590.  ■•  Tr.  Am.  Climat.  Assn.,  1905. 

6  Effect  of  Altitude  on  Blood-pressure,  Jour.  Am.  Med.  Assn.,  1915,  Ixiv,  1812. 

•Am.  Jour.  Physiol.,  1916,  xl,  380. 


56  PHYSIOLOGY  OF  BLOOD-PRESSURE 

acclimatization  and  did  not  wholly  disappear  after  a  residence  of 
two  weeks.  The  average  rise  in  systolic  pressure  after  a  quick, 
short  run  was  in  three  normal  individuals  61  mm.  Hg.  During 
exertion,  arterial  pressure  rose  more  rapidly  at  high  altitudes  than 
at  low  altitudes;  but  whereas  at  low  altitudes  the  arterial  pressure 
reaches  its  maximum,  after  exertion,  before  the  pulse  rate,  at  the 
high  altitude,  the  pulse  rate  reaches  its  maximum  before  the  blood- 
pressure. 

Age. — In  children  the  blood-pressure  has  been  declared  by 
MichaeP  to  be  more  closely  proportional  to  the  height  or  weight 
than  to  the  age  of  the  child.  Sex  during  childhood  appears  to  be 
of  no  importance. 

Systolic  pressure  (Michael), 
Weight.  mm.  Hg. 

Infancy 75  to  90 

30  to  40  pounds 95 

40  to  50   "  100 

50  to  60   "  107 

60  to  70   "  112 

70  to  80   "  116 

80  to  90   "  122 

90  to  100   "  126 

Judson  and  Nicholson^  give  the  following  table  of  averages  at 
different  ages  based  upon  a  series  of  2300  observations  made  with 
a  modified  Erlanger  method  and  by  the  auscultatory  method 
reading  the  diastolic  pressure  at  the  beginning  of  the  fourth  phase. 


Age. 

Systolic. 

Diastolic 

3  years 

91.8 

65.6 

4      " 

91.6 

64.9 

5      " 

91.3 

64.4 

6      " 

92.6 

67.3 

7      " 

94.0 

66.3 

8      " 

93.6 

64.7 

9      " 

94.3 

71.0 

10      " 

99.2 

67.1 

11      " 

97.1 

65.5 

12      " 

102.3 

65.2 

13      " 

103.6 

70.5 

14      " 

106.1 

67.4 

15      " 

105.6 

67.5 

Puring  adult  life  the  normal  systolic  blood-pressure  may  be 
inferred  from  the  following  table  from  Woley.^ 


Age. 
15  to  30  years 
30  to  40      " 
40  to  50      " 
50  to  60      " 
60  to  65      " 


Systolic  blood-pressure. 

High. 

Low. 

Average 

141 

103 

122 

143 

107 

127 

146 

113 

130 

149 

115 

132 

153 

120 

138 

>  A  Study  of  Blood-pressure  in  Normal  Children,  Am.  Jour.  Dis.  Child.,  1911,  i,  272. 
«  Am.  Jour.  Dis.  Child.,  1914,  viii,  257.  » Jour.  Am.  Med.  Assn.,  1910,  Iv,  121. 


EFFECTS  OF  ALTERATION  OF  BLOOD-PRESSURE         57 

Women  during  adult  life  average,  according  to  Woley,  about 
8  mm.  lower  in  systolic  pressure  than  males  of  the  same  age.  The 
diastolic  pressure  is  normally,  at  rest,  about  70  per  cent,  of  the 
systolic.    (See  p.  134.) 

The  average  minimal  pressure  in  healthy  young  males  of  twenty 
years  of  age  was  found  by  Weysse  and  Lutz  to  be  85  mm.  Hg.,  with 
a  maximal  pressure  of  120  mm. 

Melvin  and  Murray,^  in  a  series  of  normal  cases  using  the  aus- 
cultatory method  and  reading  the  diastolic  pressure  at  the  begin- 
ning of  the  fourth  phase,  find  the  normal  diastolic  pressure  to 
range  from  50  to  82  with  an  average  value  of  66,  or  56  per  cent, 
of  the  systolic.  This  is  much  lower,  however,  than  the  generally 
accepted  figure. 

THE  EFFECTS  OF  ALTERATION  OF  BLOOD-PRESSURE 
UPON  THE  ORGANS  OF  THE  BODY. 

I.  Effects  upon  the  Heart. — The  first  effect  of  a  sudden  elevation 
of  aortic  pressure  through  increase  of  peripheral  resistance  is,  as 
we  have  seen  (see  p.  33),  a  reflex  inhibition  of  the  heart  tending 
to  reduce  the  cardiac  output  and  restore  the  blood-pressure  to 
normal.  When  a  permanent  increase  in  the  peripheral  resistance 
develops,  be  it  the  result  of  continued  arteriolar  spasm  or  of  arterio- 
lar fibrosis,  although  the  cardiac  output  per  minute  may  be,  and 
probably  often  is,  diminished,  the  force  of  the  ventricular  systole 
is  increased  to  meet  the  higher  aortic  pressure  and  deliver  its  output 
against  this,  and  if  the  nutrition  of  the  hfeart  be  good  there  develops 
a  cardiac  hypertrophy  chiefly  of  the  left  ventricle.  It  may  readily 
be  seen  that  this  phenomenon  is  a  necessary  compensatory  adjust- 
ment if  an  adequate  blood  flow  through  the  more  resistant  arterioles 
is  to  be  maintained.  It  has  been  further  suggested  that  the  hypo- 
thetical substances  which,  circulating  in  the  blood,  have  called 
forth  the  arteriolar  spasm  may  also  act  as  a  direct  stimulant  to 
the  cardiac  muscle.  This,  for  example,  is  true  of  adrenalin.  In 
favor  of  this  view  is  the  fact  that  hypertroph}'  in  hypertension 
cases  in  man  can  be  observed,  as  a  rule,  not  only  in  the  left  ventricle 
but  in  all  four  chambers  of  the  heart;  the  hypertrophy  of  the  left 
ventricle  is  usually  greater,  however,  than  that  of  the  other  cham- 
bers (Senator)  .2  It  has  also  been  suggested,  but  less  favorably 
received,  that  the  cardiac  stimulation  is  the  primary  effect  of  these 

'  British  Med.  Jour.,  1914,  ii,  500. 

*  Die  Erkrankungen  der  Nieren,  Wien,  1902,  p.  114. 


58  PHYSIOLOGY  OF  BLOOD-PRESSURE 

hypertensive  substances,  the  arteriolar"  spasm  and  fibrosis  being 
secondary.  Experimental  evidence  bearing  upon  this  point  is 
difficult  to  obtain  and  to  interpret,  and  the  question  remains 
unsettled. 

The  final  effect  upon  the  hea,rt  of  maintaining  for  a  prolonged 
period  a  blood-pressure  considerably  above  normal  is  cardiac 
exhaustion  beginning,  as  a  rule,  with  dilatation  and  weakening  of 
the  left  ventricle.  Then  follow  with  falling  blood-pressure,  which 
may  still,  however,  be  considerably  above  the  normal,  the  signs  of 
circulatory  failure  throughout  the  body:  edema,  accumulation  of 
fluid  in  the  serous  cavities,  venous  congestion,  cyanosis,  dyspnea, 
edema  of  tlie  lungs,  renal  insufficiency,  and  the  disturbances  of 
the  internal  organs  resulting  from  passive  congestion.  This  out- 
come is  hastened  by  coronary  sclerosis,  which  impairs  the  cardiac 
nutrition.  The  effect  of  low  blood-pressure  upon  the  heart  is,  as 
a  rule,  to  call  forth  a  reflex  acceleration  of  cardiac  rate  and  activ- 
ity. So  far  as  the  coronary  circulation  suffers  from  the  lowered 
blood-pressure  a  detrimental  influence  is  exerted  on  the  cardiac 
nutrition. 

II.  Upon  Arteries  and  Arterioles. — ^Associated  with  continued  high 
blood-pressure  are,  in  the  great  majority  of  cases,  certain  changes 
in  the  vessel  walls.  These  consist  of  fibrous  thickening  of  the  inner 
and  outer  coats  of  the  arteries  and  arterioles  with  increase  of  their 
elastic  tissue.  The  muscular  coat  shows  sometimes  a  thinning, 
sometimes  a  thickening,  but  the  latter  is  due  more  often  to  increase 
of  the  fibrous  tissue  of  the  muscular  coat  than  of  the  muscle  tissue 
itself.  That  these  fibrous  changes  in  the  vessel  walls  are  the  direct 
result  of  strains  or  minute  tears  consequent  upon  the  high  blood- 
pressure  has  been  suggested.  .  That  they  are  the  direct  effect  of 
those  toxic  substances  which  have  produced  the  arteriolar  spasm 
and  high  blood-pressure  is  possible.  Finally,  in  some  cases  these 
arteriosclerotic  changes  in  the  vessel  walls  result  from  the  toxins 
of  acute  infections  or  of  syphilis  and  develop  before  any  rise  of  blood- 
pressure  has  occurred;  once  developed,  however,  they  increase  the 
resistance  to  the  flow  of  blood  through  these  vessels.  The  effect 
of  this  in  leading  in  turn  to  a  rise  of  arterial  blood-pressure  and 
eventually,  if  the  coronaries  be  not  too  sclerosed,  to  cardiac  hyper- 
trophy, will  be  discussed  later. 

ni.  Upon  Capillary  Pressure,  Venous  Pressure,  and  the  Pulmonary 
Pressure. — On  these  high  arterial  pressure  has  little  effect.  The 
arterial  pressure  is  confined  between  the  left  ventricle  on  the  one 
hand  and  the  "stopcock,"  the  arterioles,  on  the  other  hand,  and 


EFFECTS  OF  ALTERATION  OF  BLOOD-PRESSURE         59 

marked  changes  may  occur  in  the  arterial  pressure  with  no  change 
whatever  in  the  pressure  in  the  capillaries,  veins,  or  pulmonary 
vessels. 

As  we  have  noted,  the  capillary  pressure  is  dependent  more  upon 
the  venous  than  upon  the  arterial  pressure. 

IV.  Upon  the  Kidneys. — Goll's  experiments,  performed  under 
Ludwig,  were  the  first  to  show  conclusively  the  effect  of  changes  in 
blood-pressure  upon  the  activity  of  the  kidneys.  Goll  cut  the  vagi 
of  a  dog,  determined  the  blood- pressure  by  means  of  a  cannula 
introduced  into  the  carotid,  then  from  the  two  ureters  collected  all 
the  urine  excreted  for  half  an  hour.  He  then  stimulated  continu- 
ously with  a  weak  faradic  current  the  peripheral  end  of  one  of  the 
cut  vagi,  thereby  diminishing  the  cardiac  activity  and  causing  a 
fall  of  blood-pressure.  This  procedure  was  continued  for  half  an 
hour,  during  which  time  the  urine  from  the  ureters  was  again  col- 
lected. It  was  found  that  the  fall  in  blood-pressure  had  markedly 
reduced  the  amount  of  urine  excreted  in  the  half-hour  and  that  it 
had  reduced  the  water  of  the  urine  more  than  it  had  the  solids,  so 
that  while  the  actual  amount  of  solids  was  reduced,  the  percentage 
of  solids  and  the  specific  gravity  of  the  urine  were  increased. 

He  then  took  another  dog  and  similarly  recorded  the  carotid 
pressure  and  measured  the  urine  excreted  from  the  two  ureters  for 
half  an  hour.  He  then  bled  the  dog  freely;  a  fall  in  blood-pressure 
resulted  and  persisted.  During  the  next  half-hour,  while  the 
blood-pressure  was  low,  the  urine  was  again  collected  and  was  found 
as  in  the  first  experiment  to  be  reduced  in  amount;  again  the  water 
was  more  reduced  than  the  solids.  The  blood  which  had  been 
withdrawn  from  the  animal  was  defibrinated  and  at  the  end  of 
the  half-hour  was  reinjected,  restoring  the  animal's  blood-pressure 
to  about  the  original  level.  The  urine  was  now  again  collected  for 
half  an  hour  and  was  found  to  have  increased  in  quantity  to  about 
the  original  level  of  excretion  and  the  water  had  increased  more 
than  the  solids,  so  that  while  the  elimination  of  solids  had  increased, 
the'percentage  of  solids  and  the  specific  gravity  were  reduced  to 
about  normal. 

Later  Meyer  performed  the  following  experunent:  In  a  rabbit 
he  constricted  the  vena  cava  above  the  entrance  of  the  renal  veins 
to  half  its  natural  diameter.  This,  he  found,  led  to  the  excretion 
of  a  diminished  quantity  of  highly  concentrated  urine  which  con- 
tained albumin. 

It  will  be  observed  that,  although  Meyer's  experiment  increases 
the  blood-pressure  in  the  capillaries  of  the  kidney,  it  diminishes 


60  PHYSIOLOGY  OF  BLOOD-PRESSURE 

the  output  of  urine.  The  activity  of  the  kidney  is  not,  therefore, 
proportional  to  the  blood-pressure,  as  Goll's  experiment  might  sug- 
gest, but  to  the  rate  of  blood  flow  through  the  renal  vessels.  In 
both  of  Goll's  experiments  the  fall  of  blood-pressure  reduces  the 
flow  through  the  renal  vessels,  and  in  Goll's  second  experiment  the 
reinjection  of  the  blood  with  the  resultant  rise  of  pressure  increases 
the  flow  through  the  kidney.  In  the  same  way  digitalis,  which 
increases  the  amplitude  of  the  cardiac  systole  and  thus  augments 
the  cardiac  output,  thereby  raising  the  blood-pressure  and  thus 
increasing  the  blood  flow  through  the  organs,  is  a  drug  which  pro- 
duces diuresis.  On  the  other  hand,  adrenalin,  when  injected  intra- 
venously, increases  the  arterial  blood-pressure  much  more  than  does 
digitalis,  but  does  so  by  constriction  of  the  arterioles  and  therefore 
reduces  the  blood  flow  through  the  organs.  The  effect  of  a  large 
dose  of  adrenalin  upon  the  excretion  of  urine  is  to  greatly  dimin- 
ish or  entirely  stop  it  during  the  brief  period  of  the  drug's  effective- 
ness. The  comparison  of  the  effects  of  these  two  drugs  on  renal 
activity  is  a  good  illustration  of  the  impossibility  of  estimating  the 
effectiveness  of  the  circulation  by  the  arterial  blood-pressure. 

Nitroglycerin  and  the  nitrites  act  chiefly  by  dilating  the  arterioles 
and  thus  lowering  blood-pressure.  Did  they  influence  all  arterioles 
equally  their  effect  would  be  to  increase  the  blood  flow  through  all 
the  organs,  with  a  lowering  of  blood-pressure.  In  fact,  however, 
they  dilate  the  mesenteric  vessels  disproportionately.  Very  small 
doses  may  lead  to  increased  blood  flow  through  the  kidneys  with 
diuresis.  However,  larger  doses  dilate  the  mesenteric  arterioles 
so  much  more  than  the  renal  that  the  blood  flow  is  diverted  through 
the  former  with  a  fall  of  aortic  pressure,  and  the  flow  through  the 
renal  vessels  diminishes,  as  does  the  urinary  output. 

We  find,  therefore :  (1)  A  rise  in  the  general  arterial  blood-pressure 
caused  by  increasing  the  bulk  of  the  blood  or  by  augmenting  the 
cardiac  output,  increases  the  blood  flow  through  the  kidneys  and 
in  consequence  the  renal  activity.  (2)  A  change  in  the  general 
arterial  blood-pressure  (rise  or  fall),  produced  in  such  a  way  as  to 
diminish  the  blood  flow  through  the  kidneys,  diminishes  the  renal 
activity. 


CHAPTER    II. 

THE  INSTRUMENTAL  ESTIMATION  OF 
BLOOD-PRESSURE. 

No  one  who  has  had  any  experience  with  instruments  of  precision 
in  controlling  his  tactile  impressions,  will  flatter  himself  with  the 
delusion  that  he  can  gauge  endovascular  tension  with  anything 
approaching  accuracy  with  the  finger.  Extremes  are  easily  recog- 
nized but  the  intervening  moiety  is  a  fertile  source  of  error.  The 
size  of  the  vessel,  the  character  of  the  surrounding  tissues,  the 
volume  of  the  pulse  and  the  state  of  the  arterial  wall  itself,  all 
contribute  to  one's  confusion.  The  estimate  of  arterial  tension  has 
therefore  been  relegated  to  the  more  exact  field  of  sphygmoman- 
ometric  measurement,  just  as  has  the  determination  of  alterations 
of  bodily  temperature  to  the  thermometer. 

With  the  older  methods  and  with  most  of  the  early  instruments 
only  the  systolic  pressure  could  be  gauged.  This  is  no  longer  suffi- 
cient. It  is  now  possible  to  estimate  the  diastolic  pressure  with 
approximate  accuracy  by  a  number  of  different  methods.  The 
systolic  index  alone  tells  but  a  part,  and  that  but  a  small  part,  of 
the  whole  story.  No  examination  can  be  considered  satisfactory 
or  complete  which  does  not  include  the  diastolic  pressure.  Indeed, 
the  latter  is  often  more  important  than  the  systolic  reading. 

A  large  number  of  instruments  for  the  estimation  of  human 
blood-pressure  have  been  devised  and  modified.  This  gradual 
development  will  not  concern  us  here,  as  the  subject  is  mainly  his- 
toric in  its  interest  and  has  already  been  ably  described  by  others.^ 
In  many  of  the  older  instruments,  either  the  principle  was  faulty  or 
the  technic  unsatisfactory,  hence  we  shall  consider  mainly  those 
which  are  of  practical  utility  today. 

Nearly  all  of  the  modern  instruments  are  constructed  with  an 
elastic  cuff  or  arm  band  which,  when  inflated  and  encircling  one 
of  the  extremities,  compresses,  and  when  the  pressure  is  raised 
sufficiently,  obliterates  the  arterial  pulse  below  the  cuff.     This 

1  Janeway:  The  Clinical  Study  of  Blood-pressure,  New  York,  1904,  p.  43.  Tiger- 
stedt:  Lehrbuch  d.  Physiologie  d.  Kreislaufes,  Leipsic,  1893,  p.  321.  Ergebniss  der 
Physiologie,  1907,  vi,  265.     Vachide  and  Lahy:    Arch.  g4n.  de  m6d.,  1902,  pp.  339, 


62       INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

point  corresponds  to  the  systolic  pressure.  It  indicates  the  point 
at  which  the  external  pressure  is  just  sufficient  to  overcome  the 
internal  resistance  (blood-pressure,  velocity,  the  arterial  wall,  and 
the  surrounding  soft  tissues).  The  velocity  factor  is  negligible  and 
the  resistance  of  the  arterial  wall  and  soft  tissues  normally  does 
not  exceed  10  to  7  mm.  respectively.  Hill  has  shown  that  the 
obliteration  pressure  in  the  femoral  artery  of  the  dog  is  the  same 
(within  1  to  2  mm.  Hg.)  as  the  systolic  pressure  taken  in  the  opposite 
femoral  with  a  cannula  and  the  Hiirthle  manometer. 

The  amount  of  pressure  required  is  measured  by  means  of 
either  (1)  a  mercury  manometer  graded  in  millimeters;  (2)  an 
aneroid;  (3)  a  metallic  spring  manometer;  or  (4)  a  compressed-air 
manometer  with  an  indicator;  depending  upon  the  particular 
instrument  employed. 


Fig.  9. — Arm  in  cross-section  with  Riva-Rocci  cuff:  R,  outer  wall  of  rubber  tube; 
R',  inner  wall  of  rubber  tube;  <S,  screw  fastening;  D,  clamp;  C,  silk  cover;  A,  brachial 
artery ;  H,  humerus ;  T,  tube  leading  to  manometer. 

The  Character  of  the  Cuff. — The  compression  may  be  exerted  upon 
the  vessel  in  question  either  by  (a)  a  limb-encircling,  distensible 
elastic  cuff  (applied  to  a  segment  of  the  arm  or  leg),  or  (6)  by  means 
of  a  solid  or  a  fluid  pad  overlying  the  artery;  in  either  case  sur- 
rounded by  an  external  inexpansile  fabric.  Of  these  the  former  is 
more  satisfactory  (see  Fig.  9). 

The  accompanying  figures  illustrate  the  principles  involved  in  the 
application  of  a  cufif  to  the  arm.  In  Fig.  9  we  have  a  rubber  cuff 
completely  encircling  the  arm,  but  insufficiently  inflated  to  occlude 
the  artery.  In  Fig.  10  the  rubber  extends  only  part  way  around 
the  arm,  but  the  pressure  is  high  and  the  arterial  lumen  therefore 
completely  obliterated. 

The  width  of  the  cuff,  as  was  shown  by  von  Recklinghausen,^  is 

>  Ueber  Blutdruckmessung  beim  Menschen,  Arch.  f.  exper.  Path.  u.  Pharmakol., 
1901,  xl\d,  78. 


THE  CHARACTER  OF  THE  CUFF 


63 


of  vital  importance.  If  it  is  too  narrow,  readings  higher  than  the 
actual  endarterial  pressure  may  be  obtained.  The  soft  tissues  of 
the  arm  offer  considerable  resistance  to  compression,  which  may, 


Fig.  10. — Arm  in  cross-section  with  Hill  and  Barnard  cuff:  R,  outer  wall  of  rubber 
bag;  R',  inner  wall  of  rubber  bag;  <S,  strap,  fastened  by  buckle;  C,  leather  cuff; 
A,  brachial  artery;  H,  humerus;  T,  tube  leading  to  manometer. 


however,  be  largely  overcome  by  lengthening  the  segment  included 
in  the  cuff.    The  reason  for  this  is  shown  in  Fig.  11. 

If  a  distended  artery  is  partially  obliterated  by  the  pressure  of 
a  single  block — as  in  the  case  of  a  narrow  cuff — we  not  only  have 


W    W 


W     W 

Fig.  11 


to  overcome  the  internal  pressure  of  the  vessel  but  also  the  oblique 
tension  of  the  wall  and  surrounding  tissues  {W-T),  and  as  a  result 
too  high  readings  are  obtained.    With  a  series  of  blocks  exerting 


64       INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

a  similar  pressure  to  the  square  inch,  only  the  outer  blocks  (W) 
will  be  concerned  in  overcoming  the  pull  of  the  artery  and  tissues 
at  W-T,  while  the  intervening  ones  (S-S)  will  exert  their  full 
pressure. 

With  a  broad  cuff  an  error  pf  +7  to  +9  per  cent,  may  be  assumed. 
With  a  narrow  cuff  the  figure  may  reach  +40  per  cent.,  while 
the  Gartner  finger  ring  has  a  margin  of  error  of  +19  per  cent. 

Blood-pressure  instruments  based  upon  obliteration  of  the  pulse 
by  pressure  between  a  bone  and  a  rubber  bag  (temporal,  dorsalis 
pedis,  etc.)  deform  the  artery  and  shut  off  the  blood  flow  below 
the  systolic  pressure.  As  has  been  pointed  out  by  Hill  and 
McQueen,^  compression  of  the  tissues  surrounding  the  artery,  so 
as  to  block  the  venous  outlets,  is  essential  to  accuracy.  This  con- 
gests the  blood  beneath  and  beyond  the  armlet  or  bag.  The  pul- 
sating of  the  congested  mass  of  tissues  renders  armlet  or  bag  cap- 
able of  delivering  a  circular  compression  to  the  artery  and  prevents 
deformation  of  the  artery  until  the  systolic  pressure  is  exceeded. 

There  was  for  a  time  much  discussion  as  to  the  accuracy  of  von 
Recklinghausen's  contention,  caused  by  the  belief  that  a  cuff  of 
12  cm.  interfered  with  the  progression  of  the  pulse  wave  and  yielded 
subnormal  values.  But  the  correctness  of  his  view  has  now  been 
definitely  established  by  experiments  (1)  on  the  cadaver  with  arti- 
ficial circulation  (Gumprecht);  (2)  on  animals  (Fellner,  Rudinger, 
Schelling  and  others) ;  (3)  on  the  living  human  subject  (O.  Miiller 
and  Blauel,  Janeway).  A  narrower  cuff  may  be  advantageously 
employed  for  children  (3  inches,  7  cm.). 

The  outer  covering  of  the  elastic  cuff,  whether  of  canvas,  leather, 
or  cloth,  must  be  of  a  non-distensible  character  and  the  rubber 
tubing  connected  therewith  must  be  sufficiently  inelastic  to  prevent 
any  oscillation  or  stretching  with  increased  pressure.  If  these 
facts  are  overlooked  we  introduce  a  new  source  of  error  for  which 
we  should  have  to  allow  with  each  increment  of  pressure.  For  this 
reason  the  outer  covering  must  completely  enclose  the  elastic  cuff', 
which  must  not  be  allowed  to  slip  out  of  place  while  in  use.  With 
a  view  of  obviating  this  possibility,  some  cuffs  are  constructed  in 
which  the  outer  and  inner  cuffs  are  made  as  one  piece  (Vaquez, 
Uskoff,  Oliver,  Janeway). 

The  elastic  cuff  must  of  course  be  sufficiently  thin  and  flexible 
to  add  but  a  negligible  increment  to  the  manometrical  pressure. 
This  desideratum,  as  shown  by  Gumprecht,  is  easily  furnished. 

*  Theory  of  Blood-pressure  Measurement,  British  Med.  Jour.,  June  24,  1916, 
No.  2895. 


PALPATORY  METHOD  65 

The  Location  of  the  Cuff,  etc. — The  brachial  artery  is  usually 
selected  for  blood-pressure  estimation  because  of  its  accessibility, 
and  because  either  in  the  erect,  sitting,  or  recumbent  postures  it  is 
at  about  the  cardiac  level.  The  presence  of  a  thin  shirt  or  waist 
between  the  arm  and  the  cuff  produces  only  a  negligible  error.  In 
fact  it  is  much  better  to  have  a  shirt  interposed  but  evenly  dis- 
tributed than  to  have  a  tight  sleeve  or  an  undershirt  rolled  up 
into  an  arm-encircling  band  above  the  cuff.  Thick  sleeves  may 
yield  readings  from  10  to  20  mm.  higher  than  the  actual  pressure. 
In  children  the  thigh  is  often  the  preferable  site,  on  account  of  the 
smallness  of  the  arm.  In  adults,  especially  for  purposes  of  compara- 
tive study,  either  the  thigh  or  the  calf  may  be  chosen.  The  brachial 
artery  is  considered  the  site  of  choice  because  "it  gives  us  the 
systolic  lateral  pressure  within  the  subclavian,  since  brachial  and 
axillary  are  continuous  in  direction,  and  therefore  a  near  approxi- 
mation to  systolic  lateral  pressure  in  the  aorta.  This  combined 
with  estimation  of  diastolic  lateral  pressure  in  the  brachial,  which 
is  practically  the  same  as  aortic  diastolic  pressure,  gives  the  best 
insight  into  actual  variations  of  systemic  blood-pressure"  (Janeway). 
This  statement  has  been  questioned  by  some  observers  since,  as 
was  first  shown  by  Bing,  the  pressure  in  the  two  brachial  arteries 
of  the  same  individual  may  vary  20  mm.  or  more.  The  brachial 
pressure  is  generally,  but  by  no  means  invariably,  equal  to  that  of  the 
aorta. 

The  cuffs  furnished  with  the  Tech  and  the  Mercer  instruments 
are  so  constructed  that  the  stethoscope  used  for  the  auscultatory 
method  is  applied  at  the  level  of  the  cuff  and  not  below  it,  as  is 
usually  the  case.  This  gives  readings  on  the  average  10  mm. 
higher  than  those  obtained  in  the  usual  manner  and,  in  the  opinion 
of  the  author,  adds  an  unnecessary  increment  of  error. 

I.   PALPATORY  METHOD. 

A.  Estimation  of  the  Systolic  Pressure. — Method  of  Application  for 
Instruments  of  the  Riva-Rocci  Type  (Fig.  12).— The  rubber  cuff 
(  D)  (which  should  be  12  cm.  in  width)  is  applied  so  as  to  encircle 
the  arm  or  leg,  secured  by  a  non-distensible  canvas  or  leather 
cuff,  and  strapped  or  tied  snugly  in  place  (generally  above  the 
elbow  or  knee).  The  tube  connecting  with  the  rubber  cuff  is 
attached  to  the  manometer  (M)  (the  valve  C  on  the  latter  being 
opened  to  admit  air),  and  is  inflated  by  means  of  a  syringe 
bulb  or  pump  (P)  from  the  distal  side  of  the  manometer.  The 
5 


66       INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

systolic  pressure  is  read  by  placing  the  finger  on  the  radial  pulse 
and  pumping  the  mercury  well  above  the  point  at  which  the  pulse 
at  the  wrist  disappears.  We  then  close  the  valve  C,  open  the 
second  escapement  valve  E,  and  as  the  mercury  falls  note  the 
point  at  which  the  radial  pujse  again  becomes  perceptible.  If  the 
disappearance  of  the  pulse  during  gradually  increasing  pressure  is 
chosen  as  a  criterion  for  the  systolic  level,  instead  of  its  reappear- 


FiG.  12. — The  Stanton  sphygmomanometer. 


iance  after  obliteration  during  a  falling  manometrical  pressure, 
higher  values  (3  to  10  mm.  Hg.)  will  be  obtained.  The  return  of 
the  pulse  after  obliteration  is  also  a  much  more  sudden  and  well- 
marked  phenomenon  than  the  disappearance  during  an  increasing 
pressure,  and  the  exact  moment  at  which  it  occurs  is  much  easier 
to  determine.  It  is  essential,  however,  that  the  pressure  should 
be  allowed  to  drop  slowly  and  steadily,  otherwise  the  first  few  small 
beats  will  not  be  appreciated.     A  much  more  important  reason 


PALPATORY  METHOD 


67 


lies  in  the  fact  that  the  lower  reading  is  also  somewhat  nearer  the 
actual  intra-arterial  pressure,  because  we  more  or  less  counter- 
balance the  overestimation  caused  by  the  resistance  of  the  arterial 
wall  and  the  tissues  of  the  arm.  More  accurate  readings  will  be 
obtained  if  the  radial  artery  is  palpated  with  the  ball  instead  of 
the  tip  of  the  finger.  The  latter  should  rest  against  the  overhanging 
edge  of  the  radius,  thus  permitting  the  application  of  a  very 
uniform  pressure  (Hirschf elder)  (Fig.  13). 

The  reappearance  of  the  pulse  below  the  point  of  constriction 
may  be  recognized  by  other  means.  Thus,  if  instead  of  the  pal- 
pating finger  a  sphygmograph  is  attached  to  the  wrist,  or  if  a  second 
cuff  communicating  with  some  sort  of  recording  device  is  substi- 
tuted, the  return  of  the  pulse  can  be  made  manifest. 


Jiac^fus  *" 


Fig.  13. — Position  of  the  finger  in  palpating  the  radial  artery. 


B.  Estimation  of  the  Diastolic  Pressure. — The  estimation  of  the 
diastolic  pressure  was,  until  the  auscultatory  method  was  discov- 
ered and  generally  adopted,  a  more  difficult  and  uncertain  procedure. 
By  means  of  the  last-named  procedure,  however,  we  are  now  able 
to  make  readings  which  from  the  standpoint  of  accuracy  and 
celerity  compare  very  favorably  with  those  emplo;^'ed  for  the 
systolic  pressure.  The  estimation  of  the  diastolic  pressure  is  of  the 
greatest  importance  and  for  general  clinical  purposes  no  examina- 
tion can  be  considered  complete  without  it. 

The  basis  for  all  determinations  of  the  diastolic  pressure  rests 


68       INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

on  the  fact  that  when  the  pressure  in  the  brachial  cuff  is  at  the 
diastolic  level,  the  greatest  oscillation  in  the  caliber  of  that  portion 
of  the  artery  which  lies  beneath  the  cuff  will  occur.  If  the  cuff 
pressure  is  higher,  only  the  upper  portion  of  the  pulse  wave  will 
pass  through;  if  lower,  the  .artery  will  not  completely  collapse. 
Whichever  the  method  of  estimation  of.  the  minimal  pressure 
employed,  the  end  in  view  is  always  that  of  making  manifest,  in 
one  way  or  another,  the  exact  point  at  which  this  alternate 
maximum  filling  and  collapse  occurs.    Thus  by: 

1.  Palpation  (Strassburger). — ^The  radial  artery  below  the  cuff  is 
palpated  between  the  finger  and  the  radius,  while  the  manometri- 
cal  pressure  is  slowly  increased.  It  will  be  noted  that  at  a  certain 
point,  usually  quite  well  marked,  the  pulsations  suddenly  become 
throbbing  (knocking  or  bounding,  "klopfend"),  owing  to  a  com- 
plete alternate  distention  and  collapse  of  the  artery.  This  phenom- 
enon occurs  when  the  minimum  pressure  is  reached.  The  first 
bounding  pulse  is  to  be  chosen  as  the  criterion  (often  this  charac- 
teristic continues  for  some  time  during  the  rise  of  pressure).  The 
method  has  been  found  very  accurate  when  compared  to  graphic 
registration;  the  first  bounding  wave  corresponding  to  the  first 
full  wave  on  the  tracing  (Gallavardin).  Although  this  method  has 
been  highly  recommended  by  Ehret,^  who  palpates  the  brachial 
artery  immediately  below  the  cuff,  we  cannot  commend  it;  it 
requires  long  practice,  and  even  one  who  is  skilled  in  its  performance 
is  hampered  by  too  much  of  the  personal  equation. 

2.  Visualization. — With  that  pressure  in  the  cuff  at  which  the 
greatest  arterial  fluctuation  occurs,  the  greatest  oscillation  will  also 
be  transmitted  to  the  mercurial  column.  Hence  observation  of 
the  lowermost  point  of  the  maximum  mercurial  oscillation  was  for 
a  long  time  used  as  a  criterion  of  the  minimum  pressure.  Owing, 
however,  to  its  great  inertia,  mercury  is  with  difficulty  set  in  motion 
by  the  compressed  air,  but  once  in  motion  its  oscillation  may  be 
maintained  or  even  increased  by  very  slight  pressure  changes. 
Furthermore,  many  instruments  were  equipped  with  a  U-shaped 
tnanometer  so  that  the  actual  mercurial  fluctuation  was  diminished 
by  half.  It  has  been  partly  as  the  result  of  this  that  so  many 
different  instruments  have  been  placed  on  the  market,  although, 
of  course,  compactness,  portability,  and  cost  have  also  entered  into 
the  problem. 

The  Stanton  instrument  owes  much  of  its  well-deserved  popu- 

'  Ueber  eine  einfache  Bestimmungsmethode  des  diastolischen  Blutdruckes, 
Munchen.  med.  Wchnschr.,  1909,  No.  12. 


THE  AUSCULTATORY  METHOD  69 

larity  to  the  fact  that,  being  of  the  single  tube  type  and  well 
proportioned,  it  yielded  large  mercurial  excursions. 

The  maximum  oscillation  in  other  forms  of  apparatus,  spring 
manometers  (v.  Recklinghausen),  aneroids  (Pachon,  Rogers,  San- 
born), is  also  used  to  determine  the  point  of  maximum  arterial 
fluctuation. 

n.  THE   AUSCULTATORY  METHOD. 

In  1905  Korotkow  suggested  the  determination  of  blood-pressure 
by  auscultation.  Owing  to  its  simplicity,  celerity  and  accuracy 
this  method  has  supplanted  all  others  for  clinical  work. 

If,  instead  of  palpating  the  artery  below  the  compressing  cuff, 
we  apply  the  bowl  of  a  stethoscope  and  listen,  we  will  hear  a  vari- 
ety of  sounds  during  the  fall  of  the  mercurial  column.  Five  distinct 
phases  can  generally  be  made  out  and  quite  clearly  differentiated: 

(1)  A  sound  not  unlike  the  first  cardiac  sound.  (2)  This  same 
sound  plus  a  hissing  murmur.  (3)  The  murmur  disappears  and 
only  the  sound  is  heard.  (4)  The  sound  suddenly  becomes  very 
much  muffled.  (5)  The  sound  disappears.  These  phases  occur 
while  the  pressure  in  the  cuff  is  falling  in  the  order  given. 

The  first  sound  or  phase  has  been  ascribed  to  sudden  distention 
of  the  collapsed  brachial  artery,  but  more  recent  investigations 
have  shown  this  explanation  to  be  erroneous.  In  1914  Macwilliam 
and  Melvin^  noted  that  perfectly  well-developed  and  characteristic 
sounds  were  heard  when  the  artery  consisted  merely  of  a  tube  in  a 
compression  chamber.  In  other  words,  the  sound  originated  in  the 
artery  beneath  and  not  beyond  the  cuff.  More  recently  Erlanger,^ 
who  has  extensively  investigated  the  subject,  states  that  the  sounds 
are  due  to  a  water-hammer  action — the  pressure  exerted  when  the 
motion  of  a  mass  of  fluid  is  more  or  less  suddenly  checked. 

"Under  compressions  which  permit  the  pulse  to  determine  rela- 
tively wide  excursions  of  the  arterial  wall  in  the  compression  cham- 
ber, that  is,  under  compressing  pressures  ranging  from  the  systolic 
arterial  pressure  to,  and  even  a  variable  distance  below,  the  diastolic 
pressure,  the  volume  of  the  compressed  artery  increases  abruptly 
with  each  pulse.  This  permits  a  considerable  volume  of  blood  to 
enter  the  opening  artery  with  a  high  velocity.  The  motion  of  this 
column  of  blood  is,  however,  suddenly  checked  where  it  comes  into 
contact  with  the  stationary,  or  practically  stationary,  column  of 

*  The  Estimation  on  the  Diastolic  Pressure,  Heart,  1914,  v,  153. 

*  The  Mechanism  of  the  Compression  Sounds  of  Korotkoff,  Am.  Jour.  Physiol., 
1916,  xl,  1. 


70      INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

blood  filling  the  uncompressed  artery  below.  The  water-hammer 
that  is  thus  set  into  play  distends  the  arterial  wall  at  the  point  of 
impact  with  unusual  violence.  This  distention  sets  the  arterial 
wall  into  vibration  and  the  sound  is  produced."  The  onset  of  this 
phase  indicates  the  systolic  pressure. 

The  Second  Phase. — The  addition  of  a  murmur  to  the  first  sound 
is  due  to  the  formation  of  fluid  veins,  whirls,  eddies,  produced  as 
the  blood  flows  past  the  constriction  into  the  relatively  dilated 
artery  below  the  cuft'. 

The  Third  Phase. — Disappearance  of  the  murmur  is  caused  by 
sudden  vibrations  of  the  vascular  wall  produced  by  the  increased 
volume  of  blood  which,  although  diminished  in  rapidity  of  flow, 
now  reaches  the  artery  at  the  point  of  auscultation.  The  cuff 
pressure  being  diminished,  the  water-hammer  action  is  less  marked. 
This  phase  is  generally  distinctly  louder  than  the  first.     It  corre- 

Relesse  Pressure 


R  IS  in  a  Pressure 

Fig.  14 

sponds  to  the  stage  of  large  oscillation  in  the  graphic  method,  and 
its  end  occurs  simultaneously  with  the  Ehret  phenomenon  and  the 
last  of  the  maximal  graphic  waves  (see  Fig.  18). 

The  Fourth  Phase^ — muffling  of  the  sound — arises  when  maximal 
arterial  filling  and  collapse  no  longer  occur.  According  to  ]\Iac- 
william  and  IVIelvin,^  the  fourth  phase  owes  its  characteristics  to  the 
fact  that  external  pressure  has  become  insufficient  to  cause  a  flat- 
tening of  the  circular  arterial  tube.  They  believe  that  maximum 
arterial  oscillation  occurs,  not  as  stated  by  Marey  and  generally 
accepted,  at  the  point  at  which  external  pressure  in  the  cuft'  and 
internal  pressure  in  the  artery  are  exactly  counter-balanced,  but 
at  the  point  at  which  external  pressure  is  sufficient  to  distort  the 


'  This  phase,  not  mentioned  by  Korotkow,  was  first  des"ribecl  by  Ettinger:    Wicn. 
klin.  Wchnsc-hr.,  1907,  p.  992. 

2  The  Estimation  of  the  Diastolic  Blood-pressure  in  Man,  Heart,  1914,  v,  153. 


THE  AUSCULTATORY  METHOD  71 

arterial  tube  so  as  to  produce  a  half-flattening  of  the  artery.  Erlan- 
ger,  however,  found  that  "the  maximal  oscillation  can  be  obtained 
at  a  time  when,  during  decompression  the  artery  has  attained  a 
'  half-flattened'  state  only  if  the  pulse  has  an  atypical  form,  such  as 
probably  could  be  developed  under  artificial  conditions  only."  The 
onset  of  this  'phase  indicates  the  diastolic  pressure} 


Fig.  15. — The  auscultatory  method. 

TheFifth  Phase — disappearance  of  all  sound — occurs  when  normal 
arterial  relations  are  again  established.  The  onset  of  this  phase 
is  accepted  by  some  authorities  as  indicating  the  diastolic  pressure, 
although  it  seems  well  established  that  the  beginning  of  the  fourth 

1  Macwilliam,  J.  A.,  and  Melvin,  G.  S. :  The  Estimation  of  the  DiastoHc  Pressure, 
Heart,  1914,  v,  153. 


72      INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

phase  should  be  chosen  as  the  criterion.^  In  118  cases  in  which 
both  the  fourth  and  fifth  phases  could  be  definitely  identified  it 
was  found  that  the  average  difference  between  the  two  points  was 
14  mm.  Hg.2 

It  occasionally  happens  that  the  change  from  the  third  to  the 
fourth  phase  is  not  clearly  defined  and  it  is  sometimes  necessary  to 
make  several  observations  before  the  exact  point  of  change  can  be 
established.  This  is,  however,  not  often  the  case  among  those  who 
are  accustomed  to  the  auscultatory  procedure.  The  identification 
of  the  onset  of  the  fifth  phase  is  much  less  readily  established,  and 
even  when  accomplished  is  subject  to  a  much  greater  element  of 
personal  error.  Some  recent  observations  indicate  that  when  we 
are  confronted  with  sudden  changes  in  pressure  due  to  psychic 
influences  (observations  on  students),  the  fourth  phase  is  more 
consistently  established,  whereas  among  hospital  patients  the  fifth 
phase  shows  less  variability.' 

The  actual  average  duration  of  the  different  phases  as  measured 
in  millimeters  of  mercury  was  found  by  Goodman  and  Howell^ 
to  be  14,  20,  5,  6  mm.  in  the  order  given.  These  last-named  authors 
opened  up  a  very  suggestive  line  of  investigation  in  this  field  by 
measuring  the  actual  duration  of  the  different  phases  and  their 
relation  to  each  other  under  various  pathological  conditions.  In 
cases  of  aortic  regurgitation  and  hypertension,  for  instance,  the  fifth 
phase  is  persistent.  (In  aortic  insufficiency  a  pistol-shot  sound  is 
often  heard  over  the  arteries  when  no  pressure  is  being  exerted.) 
Persistence  of  the  fifth  phase  may  also  occur  in  hyperpyrexia,  exoph- 
thalmic goiter,  arteriosclerosis  and  other  conditions.  In  failing 
compensation  the  second  phase  is  said  to  be  the  first  to  show  abbrevi- 
ation. A  long  third  phase  indicates  a  powerful  systole.  This  phase 
is  also  lengthened  in  arteriosclerosis  even  in  the  presence  of  cardiac 
weakness.    The  length  of  the  fourth  phase  increases  when  cardiac 

1  Lang  and  Manswetowa,  in  comparison  with  the  Hurthle  spring  manometer, 
obtained  closely  corresponding  readings  by  taking  the  auscultatory  readings  at  the 
beginning  of  the  fourth  phase,  Deutsch.  Arch.  f.  klin.  Med.,  1908,  xciv,  441.  Fischer 
also  believes  that  the  beginning  of  the  fourth  phase  represents  the  diastolic  pressure, 
Dfcutsch.  med.  Wchnschr.,  1908,  p.  1141.  Taussig,  A.  E.,  and  Cook,  J.  E.:  Determi- 
nation of  the  Diastolic  Pressure  in  Aortic  Regurgitation,  Arch.  Int.  Med.,  1913, 
xi,  542.  Warfield,  L.  W. :  Studies  in  Auscultatory  Blood-pressure  Phenomena, 
Jour.  Am.  Med.  Assn.,  1913,  Ixi,  1254. 

*Swan,  J.  W.:  The  Auscultatory  Method  of  Blood-pressure  Determination:  A 
Clinical  Study,  Internat.  Clinics,  IV,  Series  24. 

'  Kilgore,  Berkeley,  Rowe,  and  Stabler:  A  Quantitative  Determination  of  the 
Personal  Factor  in  Blood-pressiu-e  Measurements  by  the  Auscultatory  Method, 
Arch.  Int.  Med.,  1915,  xvi,  927. 

♦Tr.  College  of  Physicians,  Philadelphia,  1911;  Am.  Jour.  Med.  Sc,  September, 
1911. 


THE  AUSCULTATORY  METHOD  73 

weakness  exists.^  Atypical  auscultatory  findings  are  often  asso- 
ciated with  cardiac  insufiiciency  (Krylow).  In  some  apparently 
normal  cases  all  the  phases  cannot  be  made  out,  but  in  the  vast 
majority,  although  some  may  be  brief,  the  five  phases  are  distinctly 
demarcated.  Variations  in  the  strength  of  successive  systoles  are 
often  better  appreciated  by  auscultation  of  the  partially  compressed 
artery  than  of  the  precordial  "tonal  arrhythmia." 


Ill 

Arterial  sound 


J I 


1121J 

mm.  Hff.     122 


A. 


Fig.  16. — Fast  drum.     Sudden  decrease  in  size  of  ptilse  wave  at  ^,  marking  the 
change  from  clear,  sharp  tone  to  dull  tone. 


ni 


Fig.  17. — Diagrammatic  representation  of  the  auscultatory  phases  (after  Galla- 
vardin).  /,  arterial  tone  (muffled);  //,  tone  and  murmur;  ///,  arterial  tone  (loud 
and  without  a  murmur) ;  IV,  muffled  sound. 


Fig.  18. — Showing  the  relationship  between  the  oscillatory  and  the  auscultatory 
phenomena  (Gallavardin) .  Here  the  end  of  the  third  phase  is  drawn  as  correspond- 
ing to  the  last  large  oscillation. 

In  estimating  blood-pressure  by  the  auscultatory  method  any 
type  of  manometer— mercurial,  aneroid,  compressed  air— may  be 
employed. 

As  a  general  rule  a  long  and  intense  murmur  phase,  beginning 

at  a  high  pressure,  points  to  a  vigorous  heart  action.    If  it  increases 

under  exercise,  we  assume  that  the  heart  is  using  its  reserve  force. 

When  the  murmur  phase  disappears  under  light  work  cardiac 

1  Goodman  and  Howell:  Univ.  Penna.  Med.  Bull.,  1910,  xxiii,  465. 


74      INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

weakness  is  implied,  while  the  splitting  of  the  tones  of  the  first 
phase  points  to  a  dilated  hypertrophy  of  the  ventricle.  If  the 
sound  or  the  murmur  is  subject  to  variations  in  duration  and  in 
intensity,  cardiac  insufficiency  is  predicated.  The  non-appearance 
of  the  murmur  phase  has  a  similar  significance.^ 

-  Temporary  Absence  of  the  Second  Phase. — It  occasionally  happens, 
as  has  been  pointed  out  by  Cook  and  Taussig,^  that  the  second  or 
murmur  phase  may  be  very  weak,  short  or  entirely  absent.  This 
is  especially  apt  to  occur  in  cases  of  hypertension  if  the  arm  is  kept 
compressed  or  the  readings  are  not  quickly  made.  Unless  the 
height  to  which  compression  is  primarily  raised  is  controlled  by 
palpation,  auscultation  may  be  begun  in  this  silent  zone.  In  such 
an  event  the  third  phase  would  be  read  as  the  systolic  pressure, 
and  an  error  of  50  mm.  might  be  made.  Such  a  mistake  may  be 
suspected  if  the  pulse-pressure  is  found  to  be  extraordinarily  small 
without  other  evidences  of  cardiac  weakness. 

The  cause  of  this  phenomenon  may,  as  suggested  by  Erlanger, 
be  due  to  the  fact  that  a  stasis  of  blood  in  the  artery  below  the 
cuff,  together  with  a  high  peripheral  resistance,  forces  open  the 
lower  segment  of  the  compressed  artery.  It  has  been  show^n  experi- 
mentally that  if  the  artery  below  the  stethoscope  be  temporarily 
occluded  while  the  compressing  pressure  remains  stationary  at  the 
level  of  the  first  and  second  phases,  the  sounds  become  faint  and 
often  disappear.^ 

INSTRUMENTS  FOR  ESTIMATING  BLOOD-PRESSURE. 
A.  RIVA-ROCCI  TYPE. 

The  new  Nicholson  sphygmomanometer  is  a  readily  portable 
mercurial  column  instrument  enclosed  in  a  metal  case.  The  lid 
when  raised  automatically  locks  in  the  upright  position  and  acts 
as  a  support  for  the  instrument  (Fig.  19). 

We  believe  this  instrument  to  be  the  best  practical  sphygmo- 
manometer yet  devised.  It  is  small,  accurate,  readily  portable 
and  well  constructed.  Nicholson  has  also  devised  an  even  smaller, 
more  compact,  cheaper,  and  yet  accurate  instrument — the  Princo 
sphygviomanovieter — which  deserves  an  equal  endorsement. 

1  Tornai,  J. :  Ueber  d.  diagnostisches  Wert  d.  auskultatorischen  Blutdruc-kmes- 
sungen,  in  besondere  vom  Standpunkt  der  Funktions-pruefung  d.  Herzens,  Ztschr. 
f.  Phys.  u.  diat.  Therap.,  1909,  xiii,  504  et  scq. 

'Auscultatory  Blood-pressure  Determination,  .lour.  Am.  Med.  Assn.,  1916,  Ixviii, 
10«8. 

'Erlanger,  J.:   Am.  Jour.  Physiol.,  1916,  xl,  113. 


INSTRUMENTS  FOR  ESTIMATING  BLOOD-PRESSURE      75 


Fig.  19. — The  new  Nicholson  sphygmomanometer.  Showing  the  method  of  con- 
necting the  unions  A'  and  B'  with  the  stopcock  A  and  the  connection  B.  The 
needle  valve  C  must  be  closed,  and  the  stopcock -4  open  as  shown  in  the  illustration. 
To  close  the  instrument  remove  the  glass  tube  H,  sliding  it  into  the  metal  holder  E. 
Fold  the  scale  down  and  then  remove  the  metal  unions  A'  and  B'.  The  lid  can 
•then  be  made  to  close  by  firm  pressure  on  its  upper  end.  The  lid  cannot  be  closed 
until  the  stopcock  M  has  been  turned  at  right  angles  to  the  tube,  and  when  so 
turned  no  mercury  can  escape.  When  closed  the  instrument  fits  into  a  morocco 
case  containing  also  the  bulb  and  cuff,  and  can  be  carried  in  the  pocket. 

Accuracy  is  assured:  (.1)  by  a  millimeter  scale,  especially  compensated  for  the 
lowering  of  the  level  in  the  mercury  reservoir;  (2)  by  the  zero  (0)  point  on  the  scale 
being  adjustable  to  the  mercury  level,  so  that  the  readings  are  not  affected  by 
climate  and  temperature  changes;  (3)  by  the  scale  reading  directly  in  millimeters 
of  mercury,  the  primary  standard,  it  does  not  have  to  be  checked  up;  (4)  by  the 
use  of  a  large  column  of  mercury;  there  is  no  separation  of  the  mercury,  and  oxida- 
tion and  capillary  errors  are  avoided;  (5)  by  the  use  of  a  steel  stopcock  and  flint- 
glass  no  amalgam  is  formed  with  the  mercury,  so  no  friction;  (6)  by  a  steel  needle 
valve  there  is  a  perfect  air  release.  The  mercury  remains  clean  owing  to  a  new 
method  of  preventing  powder  from  the  rubber  tubes  being  sucked  into  the  mercury 
roserv^oir. 

Portability.  (1)  All  parts  are  thoroughly  protected  by  a  metal  case;  (2)  by  a 
special  stopcock  no  mercury  can  be  lost;  (3)  by  stopcock  A  one  has  an  additional 
safeguard  should  the  rubber  washer  in  the  pump  leak  slightly,  until  it  can  be 
replaced  by  a  new  washer.  The  mercurial  column  can  be  absolutely  maintained 
by  closing  the  stopcock.  This  permits  of  using  the  arm  band  to  produce  Bier's 
hyperemia.  By  inflating  the  apparatus  to  50  to  60  mm.  Hg.  and  then  closing  the 
stopcock  A  one  can  maintain  the  pressure  for  any  length  of  time  desired.  This 
is  impossible  of  attainment  on  any  apparatus  not  having  this  stopcock.  This 
is  the  only  pocket  sphygmomanometer  which  has  this  special  feature.  In  addition 
to  the  above  the  apparatus  is  simple  to  operate,  using  a  wide,  soft  cuff,  and  has  an 
automatic  catch  on  the  lid  which  holds  the  instrument  in  the  upright  position  when 
in  operation.  (Manufactured  by  the  Precision  Thermometer  and  Instrument  Co., 
Pliiladelphia.) 


76       INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

This  instrument  may  also  be  obtained  furnished  with  a  Fedde 
indicator  (oscillating  index),  which  consists  of  a  vertical  tube  con- 
taining a  pith  ball,  the  excursions  of  which  during  alternations  of 
pressure  are  both  free  and  extensive,  thus  affording  signal  aid  in 
determining  the  diastolic  pressure  by  the  visual  method  (Fig.  53). 


Fig.  20. — Vertical  cross-section  of  Nicholson's  new  pocket  sphygmomanometer. 


Another  instrument  of  the  Riva-Rocci  type,  long  familiar  to 
American  physician?,  is  that  of  Janeway  (Fig.  23).  It  is  now 
supplied  with  a  metal  needle-valve  pump  instead  of  the  rubber 
bulb  depicted  in  the  illustration.^ 

The  Mercer  sphygmomanometer  is  a  mercury  instrument  the  form 
and  construction  of  which  are  shown  in  Fig.  24.  The  instrument 
may  be  clamped  to  a  table  or  held  in  the  hand  while  readings  are 
made.    The  cuff  and  bulb  are  carried  separately.^ 

'  Manufactured  by  Dressier-Beard  Mfg.  Co.,  286  Second  Avenue,  New  York. 
2  Manufactured  by  A.  Kuhlman  &  Co.,  203  Jefferson  Avenue,  Detroit,  Mich. 


INSTRUMENTS  FOR  ESTIMATING  BLOOD-PRESSURE     77 

Leonard  HiW  has  devised  a  compact  and  convenient  form  of 
mercury  sphygmometer.  It  consists  of  a  single  graduated  tube 
the  base  of  which  is  sealed  into  a  small  reservoir  in  the  lower  end 
of  which  it  opens  (£).  The  tube  leading  from  the  cuff  is  attached 
to  the  other  end  of  the  reservoir,  which  contains  the  mercury.  The 
chief  advantages  claimed  for  the  instrument  are:  (1)  The  manom- 
eter being  of  the  single  tube  variety  halves  the  error  of  reading 


PRUISION 
THtR.S.mST.ti 


Fig.  21. — Nicholson's  Princo  sphygmomanometer.  The  instrument  in  a  semi- 
folded  and  open  position.  A,  terminal  of  tubing;  B,  socket  for  the  same;  C,  stop- 
cock; D,  needle  valve;  E,  clamp  level  to  set  scale  at  proper  mercurial  level;  F,  mer- 
curial reservoir;  G,  hinge  which  permits  folding  of  calibrated  standard;  H,  auto- 
matic valve  which  permits  folding  of  manometer  tube  and  retains  mercury  when  in 
transit;  /,  scale  folded;  K,  tubing  folded;  N,  screw  cap  to  permit  removal  of  mercury. 

as  compared  with  the  U-tube  type.  (2)  Owing  to  the  capillary 
opening  the  mercury  cannot  spill.  It  can  be  carried  in  any  position, 
requires  no  rubber  caps  or  stopcocks.  (3)  Ready  portability;  no 
box  is  required;  the  wooden  case,  cuff  and  pump  can  be  carried  in 
a  handbag  (Fig.  25). 


1 A  New  Form  of  Mercury  Sphygmometer,  British  Med.  Jour.,  February  19,  1910. 


78       INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

Several  inexpensive  instruments  of  the  Riva-Rocci  type  are  on 
the  market  which,  especially  if  the  auscultatory  method  be  em- 
ployed, will  be  found  entirely  satisfactory  for  clinical  work.    Among 


Fig.  22. — Faught's  mercury  sphygmomanometer  showing  relation  of  parts,  metal 
pump,  and  special  expansion  tubing  for  inflator. 


Fig.  23. — Janeway's  sphygmomanometer. 


INSTRUMENTS  FOR  ESTIMATING  BLOOD-PRESSURE      79 

these  the  instruments  of  Linnell,^  Kercher,^  Cook,^  Sahli/  Bruhns- 
Fahraeus^  may  be  mentioned.     (See  p.  139.) 


300 


=o= 


Fig.  24. — The  construction  of  the  manometer  of  the  Mercer  instrument.  A  U-tube 
manometer  with  the  top  of  each  limb  of  the  U  closed  with  a  barometer  kid  gasket 
held  securely  in  a  metal  socket.  The  gasket  allows  the  air  to  pass  freely  but  retains 
the  mercury.  The  manometer  is  enclosed  in  an  outer  metal  casing  tube  which  is 
slotted  and  provided  with  a  direct  reading  scale.  The  shorter  limb  of  the  U  is  con- 
nected with  a  slip  socket  in  the  bottom  of  the  outer  tube  by  a  .small  metal  tube  as 
shown.     Only  glass  and  kid  come  in  contact  with  the  mercury. 


1  A  Pocket  Mercury  Manometer,  Jour.  Am.  Med.  Assn.,  October  12,  1912,  lix. 

'  Blood-pressure  apparatus  manufactured  by  Lander,  Cleary  &  Co.,  Philadelphia. 

'  Cook  sphygmomanometer  manufactured  by  the  Kny-Scheerer  Co.,  New  York. 

*  Manufactured  by  Biichi  &  Sohn,  Bern,  Switzerland. 

*  Manufactured  by  Stein  &  Werner,  Stockholm. 


80      INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

The  Gartner  tonometer^  consists  of  small  distensible  rubber  rings 
which  are  applied  to  the  finger,  and  connected  with  a  manometer. 
The  finger  is  rendered  bloodless  and  the  point  at  which  the  blanched 
skin  becomes  rosy  is  taken  as  the  criterion  of  the  systolic  pressure. 
This  instrument  yields  variable  amounts  of  error  but  is  still  occasion- 
ally employed  in  connection  with  brachial  readings  to  determine 


Fig.  25. — Hill's  sphygmometer:    A,  sphygmiometer;  B,  case;  C,  section  of  mercurial 
reservoir;  D,  brachial  cuff;  E,  pump. 


the  pressure  ratio  between  large  and  small  arteries,  in  the  hope  of 
thus  throwing  some  light  on  the  state  of  vascular  tonus  (Fig.  26). 

"  The  method  of  Gartner  is  open  to  the  objection  that  the  arteries 
of  the  fingers  are  probably  small  enough  to  participate  directly  in 
vasomotor  changes.    Therefore  a  rise  of  the  general  blood-pressure, 

'  Wien.  med.  Wchnschr.,  1899,  xlix,  1412. 


INSTRUMENTS  FOR  ESTIMATING  BLOOD-PRESSURE      81 

which  in  part  is  caused  by  constriction  of  the  digital  arteries,  may 
be  associated  with  a  fall  of  pressure  in  the  terminal  phalanges. 
That  this  does  occur  is  practically  demonstrated  by  the  fact  that 


Fig.  26. — Gartner's  tonometer. 


cold,  which  usually  causes  peripheral  constriction  with  consequent 
rise  of  the  general  blood-pressure,  seems  to  cause  a  fall  of  pressure 
as  estimated  by  the  method  of  Gartner."^ 

1  Erlanger:   The  Circulation,  Jour.  Am.  Med.  Assn.,  October  27,  1906. 
6 


82       INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 


Fig.  27. — Bishop's  blood-pressure  apparatus. 


Legend  tor  Fig.  28.  ' 
Universal  sphygmomanometroscope.  At  Janowsky's  Clinic  in  Petrograd  the 
blood-pressure  in  the  upper  extremities  is  determined  by  comparison  of  the  findings 
of  five  different  apparatus.  These  include  the  Riva-Rocci  cufif,  the  tonometer,  the 
two  spring  manometers  of  Basch  and  the  water  manometer  of  Zipliaef-Janowsky. 
N.  van  Westenrijk,  of  Petrograd,  has  succeeded  in  combining  these  various  apparatus 
in  a  single  one  in  which  one  mercury  manometer  answers  for  all.  It  is  arranged  so 
that  the  zero  point  can  be  adjusted,  and  it  allows  comparison  of  the  findings  with 
different  technic  and  registration  of  the  pressiu-e  up  to  350  mm.  Hg.  The  mercury 
tube  R  (Figs.  1  and  3)  opens  below  into  the  reservoir  R\  the  graduated  scale  (Figs.  1 
and  4)  being  fastened  within  the  mercury. tube  and  the  reservoir.  The  whole  is 
mounted  on  a  weighted  wooden  standard.  The  right-hand  branching  arm  of  the 
reservoir  R'  (Fig.  2)  is  connected  with  the  tulje  which  forks  to  the  Riva-Rocci  cuff 
E  (Fig.  1),  the  Gartner  tonometer  ring  D,  the  Basch  contrivance  for  determining  the 
pressure  in  the  capillaries  F,  the  rubber  bulb  for  determining  the  blood-pressure  in 
the  veins  G,  and  the  rubber  bulb  H  for  increasing  the  pressure  in  the  glass  chamber 
F.  All  these  are  controlled  with  stopcocks  in  the  tubes.  The  left-hand  branching 
tube  from  the  reservoir  R'  is  connected  with  the  rubber  bulb  A,  which  is  compressed 
by  a  screw  lever  to  increase  the  pressure  (Fig.  1)  in  the  cuff  and  ring  and  also  in  the 
manometer.  The  tube  B,  with  its  two  enlargements  and  capillary  lumen  (oscillom- 
eter) runs  in  the  groove  K,  and  is  brought  into  connection  separately  with  the  cuff, 
ring,  etc.,  on  the  other  side  of  the  reservoir  R',  by  turning  the  stopcock  C. 


INSTRUMENTS  FOR  ESTIMATING  BLOOD-PRESSURE      83 


Fig.  28 


The  apparatus  allows  the  Riva-Rocci  cuff  to  be  used  for  tonometry  as  well  as  in  the 
usual  manner.  The  illustrated  description  is  published  in  the  Mitteilungen  der 
Gesellschaft  f.  innere  Med.,  1908,  vii,  202.  Universal  sphygmomanometroscope, 
manufactured  by  Eberhard,  Petrograd,  Russia. 


84       INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 


What  may  be  described  as  a  home-made  blood-pressure  apparatus 
has  been  devised  by  Bishop.  The  accompanying  diagram  is  suffi- 
ciently explanatory  to  indicate  the  general  principle  upon  which 
the  instrument  is  based^  (Fig.  27). 


Fig.  29. — The  Oliver  mercurial  compressed-air  manometer. 


Fig.  30. — Hertz  sphyginomanometer.- 

For  detailed  description  see  L.  F.  Bishop:     The  Measurement  of  Human  Blood- 
pressure,  Arch.  Diag..  April,  1908. 

*  Das  Neue  Modell  meines  Blutdruckmessers,  Wien.  klin.  Wchnschr.,  1911,  No 
37,  p.  1306.  Kolomoitzew  (Miinchen.  med.  Wchnschr.,  July  20,  1909,  p.  1482), 
although  obtaining  figures  within  normal  ranges  with  this  instrument,  found  an 
acciu'ate  accordance  with  Riva-Rocci  reading  in  only  13  per  cent,  of  the  cases. 


C0MPRE3SED-AIR  MANOMETERS 


85 


B.  COMPRESSED-AIR  MANOMETERS. 


Compressed-air  instruments  are  small,  light  and  compact.  A 
small  quantity  of  mercury  or  colored  liquid  is  kept  in  the  bulbous 
end  of  the  glass  tube.  When  pressure  is  raised,  a  drop  of  this  fluid 
is  forced  up  into  the  glass  tube.  This  is 
simply  used  as  an  index  by  means  of 
which  the  height  of  the  pressure  can  be 
read  off. 

The  Oliver  Instrument.' — Method. — ^Lay 
the  instrument  on  a  flat  surface  and  lift 
the  upper  end  of  the  manometer  by  the 
brass  ring,  at  the  same  time  opening  out 
the  hinged  prop  at  the  back  to  the  ex- 
treme right-hand  corner  of  the  box.  This 
places  the  scale  at  an  angle  of  about  45 
degrees  and  facilitates  observation.  Tem- 
perature variations  are  compensated  for 
by  the  vacuum  which  surrounds  the 
pressure  chamber.  The  scale  is  in  milli- 
meters of  mercury,  having  been  stand- 
ardized. Any  mercury  remaining  in  the 
tube  may  be  shaken  down,  as  in  a  ther- 
mometer, when  the  box  is  closed.  A 
modification  of  this  instrument  is  made 
by  Tech,  of  New  York.  The  instrument 
is  simple  and  compact.  It  consists  of  the 
usual  cuff  and  inflation  bulb.  The  man- 
ometer is  of  the  compressed-air  type,  a 
drop  of  mercury  being  used  as  an  index. 
It  is  open  to  the  criticism,  however,  that 
the  small  scale  with  widely  spaced  grada- 
tions militates  against  accuracy. 

Hertz's  Sphygmomanometer. — Method. — 
After  application  to  the  wrist  as  shown 
in  the  illustration,  the  cautery  bulb  /  is 

tensely  inflated,  the  clip  d  cutting  off  communication  with  the  cuff. 
When  this  is  accomplished  the  clip  d  is  opened  and  the  droplet  of 
mercury  approaches  the  distal  end  of  the  manometer.    The  systolic 


^B 


Fig.  31.— The  Benedick  In- 
strument. Diagram  showing 
the  glass  tube  of  the  water 
sphygmomanometer:  A,  bulb 
partially  filled  with  water  on 
which  pressure  is  exerted  by 
a  column  of  air  in  the  tube 
leading  from  the  cuff ;  B,  level 
of  water  in  upright  calibrated 
tube  C,  which  contains  air 
above ;  D,  bulb  in  the  tube 
C,  to  contain  the  air  as  the 
water  rises.  At  the  top  of 
the  tube  is  a  cock  for  closing 
the  tube  after  the  water  is 
put  in  below. 


'  Manufactured  by  Dressier-Beard  Mfg.  Co.,  386  Second  Avenue,  New  York. 


86      INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

pressure  is  read  at  the  point  at  which  the  radial  pulse  disappears; 
the  diastolic  pressure,  at  that  at  which  the  pulse  becomes  dimin- 
ished in  volume. 

Benedick's  Air-water  Sphygmomanometer^  is  calibrated  in  milli- 
meters of  mercury.  Water  is  poured  into  the  reservoir  until  the 
points  A  and  B  are  reached.  The  stopcock  is  then  closed  above  D. 
The  pressure  in  the  cuff  is  exerted  on  the  fluid  at  A  and  transmitted 
to  B  while  the  air  in  the  column  is  being  compressed.    The  bulb 


Fig.  32. — Benedick's  air-water  sphygmomanometer. 

acts  as  a  reservoir  for  the  fluid,  the  bulb  B  for  the  air,  allowing 
the  liquid  to  rise  the  entire  length  of  the  tube  in  recording  pressures 
up  to  300  mm.  Hg.  The  two  bulbs  allow  for  a  larger  and  more 
accurate  scale  than  is  the  case  where  straight  tubes  are  used.  The 
metal  T-tube  with  a  stopcock  and  needle-valve  escapement  allows 
the  air  pump  to  be  disconnected  and  controls  the  fall  of  pressure. 

'A  New  Air-water  Sphygmomanometer,  Jour.  Am.  Med.  Assn.,  1911,  Ixi,   1873. 
Manufactured  by  Eimer  &  Amend,  205  Third  Avenue,  New  York  City. 


CHAPTER  III. 

THE  INSTRUMENTAL  ESTIMATION  OF  BLOOD- 
PRESSURE  (Continued). 

in.  The  Graphic  Method  of  Estimating  Blood-pressure. — If  instead 
of  employing  the  finger  below  the  cuff  in  order  to  determine  the 
presence  and  character  of  the  pulse  wave,  a  sphygmograph  is 
substituted,  one  obtains  a  graphic  tracing  of  the  appearance, 
increase,  maximum  oscillation,  and  final  disappearance  of  the 
pulse,  which  occurs  while  the  pressure  in  the  cuff  is  falling  from 
above  the  systolic  to  below  the  diastolic  pressure.  Such  a  procedure 
has  the  advantage  of  furnishing  a  permanent  record,  and  also  of 
allowing  one  to  judge  more  accurately  the  exact  point  at  which 
the  maximum  pulsation  is  established.  The  graphic  method  is 
therefore  employed  where  the  greatest  accuracy  is  demanded,  as 
in  experimental  work. 

In  the  instruments  of  Erlanger,  Uskoff,  Muenzer,  instead  of  a 

sphygmograph  on  the  radial  artery,  the  brachial  pulsation  of  the 

cuff  itself  is  transmitted  indirectly  to  a  kymograph.    "Indirectly," 

•  because  the  pressure  in  the  cuff,  were  it  not  "stopped  down,"  would 

be  too  great  for  the  delicate  membranes  connected  with  the  tambour. 

The  systolic  pressure  is  determined  by  noting  with  a  decreasing 
pressure  the  point  at  which  the  first  full  pulse  wave  is  transmitted 
to  the  drum.  While  the  cuff  pressure  is  still  above  this  level  a  series 
of  small  elevations  often  appear  which  are  due  to  the  impaction 
of  the  pulse  wave  against  the  upper  margin  of  the  cuff,  the  central 
portion  of  which  still  occludes  the  blood  flow. 

The  lower  end  of  the  maximum  excursions  is  generally  taken  as 
an  indication  of  the  diastolic  pressure  because  at  this  point  there 
is  just  sufficient  pressure  in  the  cuff  to  cause  a  complete  diastolic 
collapse  of  the  artery,  while  at  the  same  time  permitting  a  com- 
plete distention  during  systole.  Pressure  on  either  side  of  the  cuff 
being  about  equal,  although  alternate,  the  greatest  oscillation  of 
the  interposed  membrane  occurs.  Below  this  level  the  excursions 
grow  progressively  less  because  with  the  falling  manometrical 
pressure  less  and  less  of  the  arterial  pulsation  is  transmitted  to 
the  gradually  loosening  cuff.  In  some  cases  it  is  difficult  to  deter- 
mine the  exact  point  at  which  the  inframaximal  pulsations  begin. 


88      INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

When  the  diastolic  pressure  is  being  estimated  by  the  graphic 
method  it  sometimes  happens  that  two  regions  of  maximum  oscilla- 
tion occur.  "The  first  diminution  in  ampHtude  occurs  apparently 
at  the  moment  the  blood  begins  to  reenter  the  arm  with  considerable 
velocity.  The  amplitude  agaiiji  increases  when  the  vessels  of  the 
arm  become  distended  with  blood."  The  second  maximum  is 
undoubtedly  the  minimum  pressure  (Erlanger  and  Hooker). 


Fig.  33. — Pulse  tracing  made  with  the  Gibson  instrument.  Here  the  first  full  pulse 
wave  (»S)  indicates  the  systolic  pressure.  It  is  the  first  wave  which  has  overcome  the 
pressure  in  the  brachial  cuff  and  reached  the  radial  artery.  Preceding  the  point  5 
a  number  of  small  waves  are  seen  which  are  produced  by  the  impact  of  the  pulse 
waves  against  the  upper  portion  of  the  brachial  cuff,  a  segment  of  the  artery  being 
still  obliterated.  Tracing  taken  by  rapid  inflation  and  gradual  escape  with  quickly 
revolving  cylinder.  It  shows  systolic  pressure  to  be  170;  diastolic  pressvire,  according 
to  Gibson,  106  (D);  and  by  Masing's  method,  90  (D').     (Tracing  after  Gibson.) 

Occasionally  a  successive  series  of  maximum  waves  at  about  the 
diastolic  level  are  observed.  This  is  attributed  by  Sahli  to  two 
factors:  (1)  With  increasing  compression,  when  the  minimal 
pressure  is  exceeded,  the  pulse  wave  undergoes  a  stasis  underneath 
the  (broad)  cuff  which  increases  the  pulsatile  excursions  of  the 
tonograph.  (2)  At  the  same  time  a  continuously  diminishing 
amount  of  the  sphygmographic  wave  becomes  available  for  trans- 
mission. These  effects  tend  to  counteract  each  other  and  the 
resulting  waves  will  vary  according  to  which  of  the  two  effects 
predominates.  Another  explanation  is  that  the  collapse  of  the 
artery  being  gradual,  at  first  only  that  portion  of  the  artery  which 


GRAPHIC  METHOD  OF  ESTIMATING  BLOOD-PRESSURE    89 

underlies  the  centre  of  the  cuff  is  compressed;  some  time  is  required 
before  the  whole  segment  is  similarly  affected  (von  Recklinghausen). 
According  to  this  argument,  with  a  rising  pressure  one  should  choose 
the  beginning  of  the  large  oscillations  as  the  diastolic  criterion. 
This  source  of  confusion  may  be  obviated  by  the  simultaneous 
employment  of  a  brachial  and  a  radial  cuff,  in  which  event  the 
lower  cuff  will  show  a  distinct  oscillatory  diminution  the  moment 
the  diastolic  level  in  the  upper  cuff  is  exceeded. 

If  the  pressure  "be  allowed  to  fall  more  slowly  than  in  von 
Recklinghausen's  experiments  the  maximum  oscillations  will  be 
followed  immediately  by  the  abrupt  diminution  in  amplitude — 
the  diastolic  pressure  corresponds  with  the  abrupt  diminution  in 
amplitude"  (Erlanger). 

Gibson  advised  selecting  the  middle  point  of  the  greatest  ampli- 
tude of  oscillation  as  the  diastolic  point  (Fig.  37).  Strassburger 
takes  the  point  at  which  the  previous  maximal  oscillation  begins 
to  diminish  under  increasing  pressure.  Macwilliam  and  Melvin,^ 
who  have  investigated  the  relation  of  the  diastolic  pressure  to  the 
maximum  oscillation,  believe  that  the  latter  occurs  not  at  the  point 
at  which  internal  and  external  arterial  pressure  are  equalized,  but 
when  a  "  half -flattening"  of  the  arterial  lumen  is  brought  about. 

Erlanger^  has  carefully  re-investigated  the  significance  of  critical 
pressure  oscillations  by  means  of  a  circulation  schema,  in  the  hope 
of  harmonizing  the  at  present  conflicting  interpretations.  As  a 
result  of  these  experiments  he  arrives  at  the  following  conclusions : 

"1.  In  the  case  of  one  and  the  same  tube  or  artery  the  general 
configuration  of  the  record  of  the  compression  pulses  depends  upon 
(a)  the  compressibility  of  the  compression  space  and,  if  that  is 
sufficiently  small,  upon  (6)  the  phase  of  the  pulse  cycle  in  which  the 
compression  space  is  closed.  The  variations  in  configuration  may  be 
so  marked  under  the  different  conditions  as  to  show  maximum 
oscillations  at  systolic,  diastolic  or  mean  compression  pressures. 
Some  of  the  discrepancies  in  the  views  held  with  regard  to  the 
significance  of  critical  oscillations  undoubtedly  are  attributable 
to  the  differences  in  the  experimental  conditions  enumerated  above. 

"2.  The  configuration  of  the  oscillation  record  is  influenced  also 
by  the  extensibility  of  the  artery,  by  the  significance  of  the  upper 
and  lower  conical  closures  of  the  artery  relative  to  that  of  the 
completely  occluded  part  between  (length  of  artery),  and  by  the 

'  The  Estimation  of  Diastolic  Pressure  in  Man,  Heart,  1914,  v,  153. 
*  Studies  in  Blood-pressure  Estimations  by  Indirect  Methods,  Am.  Jour.  Physiol., 
1916,  xxxix,  No.  4. 


90      INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

relation  of  the  volume  of  the  undistended  bore  to  that  of  the  dis- 
tended bore  of  the  artery  in  the  compression  chamber. 

"3.  When  the  compression  space  is  sufficiently  large  the  com- 
pression oscillations  are  proportional  to  the  volume  changes  of  the 
artery  produced  by  the  pulse  and  to  the  compressing  pressure. 

"4.  The  volume  change  with  each  pulse  is  then  determined  by 
the  difference  between  the  volume  of  blood  in  the  artery  under  the 
compression  chamber  during  diastole  and  during  systole. 

"5.  During  decompression  the  diastplic  volume  increases  con- 
stantly though  along  three  successive  gradients,  each  of  which  is  in 
the  main  determined  by  a  different  process,  namely  (in  the  order 
of  their  appearance) :  (a)  the  descent  of  the  upper  conical  closure 
of  the  artery,  (6)  the  ascent  of  the  lower  conical  closure,  and  (c) 
the  filling  of  the  intermediate  segment  of  the  artery  to  its  undis- 
tended bore  (at  diastolic  compression)  and  the  subsequent  stretching 
of  the  arterial  walls  at  compression  below  diastolic  pressure. 

"  6.  The  systolic  volume  also  increases  constantly  and  along  three 
gradients  determined  by  the  following  processes  respectively: 
(a)  the  descent  of  the  upper  conical  closure,  (6)  the  filling  of  the 
central  segment  to  its  undistended  bore  (at  systolic  compression), 
and  (c)  the  subsequent  stretching  of  the  arterial  wall. 

"  7.  The  diastolic  and  systolic  volume  gradients  are  so  related  to 
each  other  that  the  compression  oscillations  determined  by  their 
separation  in  different  stages  of  decompression,  have  the  relative 
amplitudes  usually  seen  in  records  of  the  blood-pressure  made  by 
the  oscillatory  method;  though  it  is  obvious  that  as  a  result  of  dif- 
ferences in  the  relative  significance  of  the  factors  determining  the 
systolic  and  diastolic  gradients  variations  from  the  typical  record 
must  frequently  occur.  Thus  the  slight  diminution  in  the  amplitude 
of  the  oscillations  frequently  observed  before  the  sudden  diminution 
begins  is  attributable  mainly  to  an  increase  in  the  influence  of  the 
lower  conical  closure  of  the  artery. 

"8.  However,  under  all  circumstances,  natural  as  well  as  artificial, 
a  sudden  increase  and  a  sudden  decrease  in  the  amplitude  of  the 
oscillations,  if  present,  indicate  accurately  the  systolic  and  diastolic 
pressures  respectively. 

"9.  It  is  shown  that  with  a  pulse  of  the  configuration  of  the 
arterial  pulse  the  maximal  oscillation  must  be  and  is  recorded  at  a 
time  when  the  artery  is  still  collapsed  in  the  diastolic  phase  of  the 
pulse  cycle  by  the  pressure  from  without.  The  maximal  oscillation 
can  be  obtained  at  a  time  when,  during  decompression  the  artery 
has  attained  the  'half-flattened'  state  (Macwilliam  and  Melvin) 


GRAPHIC  METHOD  OF  ESTIMATING  BLOOD-PRESSURE     91 

only  if  the  pulse  has  an  atypical  form,  such  as  probably  could  be 
developed  under  artificial  conditions  only, 

"10.  During  decompression  a  slight  flow  of  blood,  which  soon 
becomes  faintly  pulsatile,  begins  about  10  mm.  of  mercury  above 
the  compressing  pressure  at  which  a  brusque  pulse,  undoubtedly 
marking  the  first  opening  out  of  the  artery  from  the  'collapsed' 
state,  appears." 

If  a  tracing  is  taken  from  the  artery  below  the  seat  of  compres- 
sion a  sphygmographic  curve  results.  In  such  a  curve  the  onset 
of  the  large  waves  is  accompanied  by  a  change  in  the  form  of  the 
waves.  At  the  upper  systolic  level  of  the  large  waves  the  pulse 
previously  anacrotic,  becomes  katacrotic;  at  the  lower  level  the 
diastolic  wave  falls  away  almost  vertically  instead  of  obliquely 
(von  Recklinghausen).  These  facts  furnish  us  with  a  further 
means  of  recognizing  the  diastolic  pressure  provided  we  are  able 
to  recognize  the  katacrotic  notch. 

The  diastolic  pressure  by  the  graphic  method,  as  shown  by 
Miiller  and  Blauel,  may  be  as  much  as  28  per  cent,  too  high. 
Although  the  artery  at  once  increases  its  oscillations  when  the 
diastolic  level  is  reached,  it  takes  some  time  for  a  complete  arterial 
collapse  to  be  established. 

The  systolic  pressure  cannot  always  be  absolutely  determined 
because  of  the  primary  small  subsystolic  waves  due  to  concussion 
of  the  upper  border  of  the  cuff.  The  diastolic  pressure  cannot  always 
be  absolutely  measured  because  (1)  there  is  still  a  difference  of 
opinion  as  to  which  criterion  should  be  used  (beginning,  middle, 
or  end  of  the  large  waves  or  the  onset  of  the  anacrotic  notch),  and 
(2)  because  it  is  not  always  possible  to  determine  the  exact  point 
at  which  these  changes  occur.  But  since  it  is  admitted  that  clinical 
blood-pressure  readings  are  approximate  estimations  only,  and  not 
exact  mathematical  calculations,  the  results  obtained  will  be  suffi- 
ciently accurate  for  practical  purposes. 

Since  the  foregoing  lines  were  written,  corroboration  of  the  state- 
ments made  has  been  furnished  by  the  investigations  of  Kilgore,* 
who  showed  that  identical  tracings  made  with  the  Erlanger  appara- 
tus were  very  variously  interpreted  by  different  individuals,  even 
by  those  who  were  familiar  with  the  instrument  and  who  were 
using  the  same  criteria  of  the  systolic  and  the  diastolic  pressures. 

Erlanger  states  that  these  discrepancies  can  be  minimized  if 
not  actually  obviated  by  (1)  using  as  the  systolic  criterion  the 

>  The  Large  Personal  Factor  in  Blood-pressure  Determinations  by  the  Oscillatory 
Method,  Arch.  Int.  Med.,  1915,  xvi,  893. 


92       INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

change  in  form,  with  the  paper  moving  at  sufficient  speed  for  this 
purpose;  (2)  by  using  the  first  cotisistent  decrease  in  ampHtude  as 
the  diastoHc  index;  and  (3)  in  doubtful  cases  controlUng  the  read- 
ings made  by  the  method  of  continuous  escapement  by  readings 
made  by  that  of  intermittent  escapement.^ 

C.  INSTRUMENTS  FOR  GRAPHIC  REGISTRATION. 

When  using  the  graphic  method,  some  sort  of  an  automatic 
registering  device  should  be  attached  to  the  instrument,  for  other- 
wise one  is  forced  to  mark  by  hand  the  various  pressure  levels  on 
the  moving  paper  while  watching  the  fall  of  the  manometer,  a 
procedure  which  is  always  irksome  and  often  inaccurate.  Various 
devices  have  been  employed  to  obviate  this  necessity  by  substi- 
tuting an  automatic  indicator  which  marks  the  varying  height  of 


Fig.  34. — The  Jacquet  sphygmotonograph. 

pressure  upon  the  record.  Thus  in  case  of  the  sphygmotonograph 
of  Jacquet-  (Fig.  34)  the  stylet  of  a  small  metallic  manometer 
communicating  with  the  brachial  cuff  registers  directly  on  the 
tracing.  The  beginning  of  the  curve  represents  50  mm.  Hg.,  and 
each  elevation  of  1  mm.  on  the  tracing  is  equivalent  to  a  pressure 
increase  of  10  mm.  Hg.  This  device  can  be  attached  to  the  regular 
Jacquet  cardiosphygmograph  and  has  the  endorsement  of  Gal- 
lavardin.  It  is  open  to  the  criticism  which  applies  to  all  metallic 
manometers — the  necessity  of  standardization.^ 
BingeP  has  devised  an  instrument  in  which  every  pressure  change 

•  Erlanger,  J.:   An  Analysis  of  Dr.  Kilgore's  Paper,  etc.,  ibid.,  p.  917. 

'  Manufactured  by  C.  &  E.  Streisguth,  Strasburg,  Germany.  A.  H.  Thomas  & 
Co.,  Philadelphia  agents. 

'  Sill>ermann,  who  has  studied  the  changes  which  occur  in  the  diastolic  portion  of 
the  sphj'gmogram  diu^ing  an  increasing  cuff  pressure,  believes  that  some  deductions 
can  thus  be  drawn  concerning  the  amount  of  vascular  tonus.  Neue  Untersuchungs- 
ergebnisse  bei  d.  Blutdruckmessung  mittels  des  Tonographen,  Deutsch.  Aerzte- 
Zeitung,  May  15,  1909. 

*  Uel>er  Messung  des  diastolischen  Blutdruckes  beim  Menschen,  Miinchen.  med. 
Wchnschr.,  190G,  xxvi,  1246.     Manufactured  by  Albrecht,  Tubingen,  Germany. 


INSTRUMENTS  FOR  GRAPHIC  REGISTRATION 


93 


of  10  mm.  is  marked  on  the  tracing  by  the  interruptions  of  an 
electric  current.  This  spacing  is  rather  wide  even  for  clinical 
purposes. 

The  sphygmomanometer  deviled  by  G.  A.  Gibsov}  (Fig.  36)  con- 
sists of  "a  mercurial  manometer,  the  lumen  of  which  is  exactly 
that  of  the  ordinary  physiological  kymograph."  The  air  contained 
in  the  armlet  can  be  increased,  and  the  pressure  on  the  limb  there- 
fore elevated,  by  means  of  a  large  syringe,  and  the  pressure  may 
be  raised  quickly  or  slowly,  according  to  requirements.  By  means 
of  a  valve  the  pressure  may  also  be  lowered  quickly  or  slowly. 
A  float  rests  upon  the  mercury,  surrounded,  as  is  usual  in  the 
physiological  laboratory,  by  alcohol,  and  an  upright  rod  of  aluminum 
leads  to  a  horizontal  arm  which  writes  on  the  revolving  cylinder. 
In  order  to  have  the  absolute  zero,  a  fixed  arm  traces  the  abscissa 


Fig.  35. — Cross-section  of  the  registering  metallic  manometer  of  Jacquet. 

upon  the  cylinder,  which  is  driven  by  a  clock-work  placed  hori- 
zontally, as  in  the  instrument  of  Erlanger.  The  pulsations  of  the 
artery  below  the  point  of  compression  are  recorded  by  means  of  a 
transmission  sphygmograph.  This  consists  of  a  tambour  brought 
into  contact  with  the  brachial  or  radial  artery,  as  may  be  most  con- 
venient, by  a  pelotte  resting  upon  the  vessel.  It  is  adjusted  to  the 
arm  by  means  of  a  spring  provided  with  a  screw.  This  tambour 
is  brought  into  communication  by  rubber  tubing  with  another 
tambour,  the  movements  of  which  are  recorded  on  the  cylinder 
simultaneously  with  the  movements  of  the  kymograph.  The 
best  tracing  is  obtained  when  the  tambour  in  contact  with  the 
artery  is  larger  than  that  connected  with  the  recording  lever  by 


1  Quart.  Jour.  Med.,  1907,  i,  103. 


94      INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

means  of  which  the  movements  are  amplified.    The  whole  appa- 
ratus is  shown  in  Fig.  36., 

"In  using  the  instrument  the  pressure  within  the  cuff  may  be 
raised  gradually  or  quickly,  the  latter  being  the  more  usual  course. 


Fig.  36. — Gibson's  sphygmomanometer.  The  recording  sphygmomanometer 
described  in  the  text:  1,  armlet;  £,  manometer;  3,  scale;  ^,  valve  for  regulating 
pressure;  5,  clip,  acting  as  a  valve  to  syringe;  6,  inflation  syringe;  7,  support  for 
transmission  sphygmograph;  8,  pelotte;  9,  screw  for  adjusting  sphygmograph  to 
artery;  10,  clip  for  arranging  pressure;  11,  recording  lever  of  manometer;  12, 
weighted  thread  for  adjusting  lever;  13,  tambour  recording  movements  of  transmis- 
sion sphygmograph;  H,  arm  marking  abscissa;  15,  revolving  cylinder;  16,  clock-work. 


If  it  is  slowly  raised,  the  tracing  of  the  kjnmograph  shows  at  first 
a  line  of  ascent  with  small  oscillations,  but  as  it  rises  the  pulsations 
become  more  and  more  marked,  and  the  excursion  of  the  index 
more  extensive,  until  a  maximum  point  of  amplitude  is  attained, 
when  they  begin  to  diminish  and  gradually  disappear.     Simul- 


INSTRUMENTS  FOR  GRAPHIC  REGISTRATION 


95 


taneously  the  transmission  sphygmograph  records  a  gradual 
diminution  in  the  amphtude  of  the  pulsations,  which  finally  cease. 
When  all  the  movements  of  the  kymograph,  as  well  as  of  the  sphyg- 
mograph, have  come  to  an  end,  the  pressure  is  allowed  to  fall  by  the 
escape  of  air  from  the  valve,  and  the  events  which  follow  are  the 
converse  of  those  just  described."  Such  a  tracing  is  shown  in  Fig.  37. 
The  manometer  is  of  the  double  column  (U-shaped)  variety 
and  in  reading  the  record  the  height  of  the  abscissa  must  be  doubled, 
e.  g.,  actual  reading  60  mm.,  corrected  reading  120  mm. 


Fig.  37. — Tracing  obtained  by  slow  inflation  and  slow  continuous  escape.  The 
ascending  curve  shows  the  pressure  to  be  180  systolic  and  120  diastolic.  The  descend- 
ing curve  shows  it  to  be  180  systolic  and  118  diastolic. 


If  the  pressure  in  the  cuff  is  allowed  to  fall  continuously,  the 
oscillating  mercury  acquires  a  progressively  increasing  momentum 
which  tends  to  depress  the  lowest  point  of  movement  beyond  its 
true  level.  This  point  is  well  illustrated  in  Fig.  38,  a  tracing  taken 
by  the  method  of  intermittent  escapement.  In  order  to  obviate 
this,  Gibson  advocates  choosing  the  mean  instead  of  the  lowest 
point  of  the  curve  when  reading  the  diastolic  pressure. 

The  advantage  of  this  instrument  over  that  of  Erlanger  lies  in 
the  fact  that  the  height  of  the  mercurial  column  is  automatically 
recorded,  and  that  the  personal  equation  is  entirely  eliminated. 
Its  disadvantage  in  relation  to  the  former  is  due  to  the  inertia  of 
the  mercurial  column  which  renders  it  less  sensitive  to  delicate 


96      INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

pressure  changes.  A  closely  similar  instrument  has  been  devised 
by  C.  Singer,^  which  is  better  adapted  to  clinical  purposes  in  being 
less  bulky  and  heavy,  without  sacrificing  accuracy. 

The  Erlanger^  sphygmomanometer  is  an  instrument  somewhat 
similar  to  that  last  described.  ,  Owing  to  its  size  and  construction 
it  is  better  suited  for  the  research  laboratory  than  for  the  hospital. 
It  has  the  advantage  of  yielding  permanent  graphic  records,  but 
necessitates  considerable  skill  in  its  employment. 


Fig.  38. — Tracing  taken  by  rapid  inflation  and  gradual  intermittent  escape,  inter- 
rupted approximately  after  each  descent  of  5  to  10  mm.  Hg.  It  shows  a  systolic 
pressure  of  118,  and  a  diastolic  pressure  of  74.  The  varying  effects  of  inertia  are  to 
be  observed,  as  described  in  the  text.     (After  Gibson.) 


While  somewhat  complicated  in  construction  it  differs  from 
other  instruments  of  this  type  chiefly  in  its  method  of  recording 
pulsations.  A  U-shaped  manometer  connects  by  means  of  a  four- 
way  tube  with  (1)  the  arm  cuff;  (2)  a  special  stopcock;  (3)  a  rubber 
bulb  enclosed  in  an  outer  glass  bulb.  The  latter  is  interposed  in 
drder  to  reduce  the  pressure  between  the  cuff  and  the  delicate 
tambour.  Records  are  made  on  smoked  paper  on  a  kymographion 
by  means  of  an  aluminum  needle  (Fig.  39).  The  pump  consists  of 
a  Politzer  bag,  and  heavy,  rigid  tubing  is  employed. 

'  A  Clinical  Apparatus  for  Obtaining  Graphic  Records  of  Blood-pressure,  Lancet, 
February  5,  1910,  p.  365.  Manufactured  by  Hawksley  &  Son,  London.  The  instru- 
ment fits  into  a  case  I45  x  5  x  4  inches;  the  cuff  is  carried  in  the  cavity  of  the  cylinder. 
The  tracings  are  made  with  ink  pens  upon  white  paper. 

2  Johns  Hopkins  Hosp.  Rep.,  1904,  xii,  62. 


INSTRUMENTS  FOR  GRAPHIC  REGISTRATION  97 


Fig.  39. — Erlanger's  sphygmomanometer. 


98      INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

Some  little  time  is  required  to  make  the  records  and  considerable 
familiarity  with  the  instrument  is  necessary,  but  graphic  records 
eliminate  subjective  errors.  It  can  be  obtained  with  polygraphia 
attachments  and  used  to  make  pulse  tracings,  but  is,  so  far  as  the 
blood-pressure  is  concerned,  not  automatically  recording,  i.  e.,  the 
height  of  the  mercurial  column  must  be  observed  and  recorded 
by  the  operator  while  the  tracing  is  being  made. 

The  systolic  readings  obtained  with  this  instrument  average 
5  mm.  higher  than  with  the  Riva-Rocci  method  with  a  broad  cuff. 
The  diastolic  readings  correspond  within  a  range  of  from  5  to  15  mm. 


Fig.  40. — The  UskoflF  sphygmotonograph. 

-  The  Uskqjp  sphygmotonograph  (Fig.  40)  was  devised  with  the 
intention  of  supplying  a  portable  instrument  which  could  be  used 
both  for  blood-pressure  and  for  pulse  tracings.  The  latter  function 
it  excellently  fulfils,  furnishing  good  simultaneous  tracings  of  the 
brachial  artery  and  any  one  other  desired  pulsation,  and  requiring 
practically  no  adjustment. 


'  Dcr  Sphygmotonograph,  Ztschr.  f.  kUn.  Med.,  1908,  Ixvi,  1  and  2. 
by  E.  Zimmerman,  Leipsic. 


Manufactured 


INSTRUMENTS  FOR  GRAPHIC  REGISTRATION  99 

Blood-pressure  tracings  taken  with  this  instrument  and  auto- 
matically registered  by  an  extremely  ingenious  escapement  device 
are  for  two  reasons  not  satisfactory.  (1)  Owing  to  the  smallness 
of  the  opening  which  connects  tbe  interior  of  the  glass  bulb  with 
the  atmospheric  air,  large  pulsations  will  transmit  relatively  more 
of  their  movement  to  the  tambour  than  is  the  case  with  small 
pulsations.  As  a  result  of  this,  neither  the  sudden  change  from 
large  to  small  pulsations  (diastolic  pressure),  nor  yet  the  change  in 
the  type  of  the  individual  waves  which  should  appear  at  this  point 
(see  p.  91)  are  demonstrable  (Staehelin  and  Faustus^).  (2)  The 
rubber,  glass-enclosed  balloon  exerts  variable  degrees  of  tension 
for  increasing  increments  of  pressure,  largely  owing  to  the  effect 
of  the  silk  netting  by  which  it  is  surrounded  (Erlanger^). 

The  author,  who  has  used  this  instrument  in  practice  for  several 
years  on  account  of  its  other  excellent  features,  having  long  since 
become  convinced  of  the  inaccuracy  of  the  blood-pressnre  tracings, 
has  employed  it  with  entire  satisfaction  as  a  simple  manometer 
in  connection  with  the  auscultatory  method.  The  driving  mech- 
anism for  tbe  tracing  is  now  furnished  with  two  speeds,  and  a  roll 
of  smoked  paper  25  meters  in  length,  thus  eliminating  two  of  its 
early  shortcomings. 

The  Uskoff  sphygmotonograph  simultaneously  records  the 
following : 

(a)  Blood-pressure  in  millimeters  of  mercury. 

(b)  Carotid  pulse  (or  jugular  pulse  or  apex  beat). 

(c)  Arterial  pulsation  from  the  upper  arm  (brachial)  at  varying 
pressures  (systolic  and  diastolic). 

(d)  Time  in  one-fifth  second. 

In  other  words,  there  are  four  tracings  upon  the  paper,  three  of 
which  are  fixed  by  the  limits  of  the  apparatus,  i.  e.,  blood-pressure 
in  millimeters  of  mercury,  arterial  pulsations  at  various  pressures 
and  time  tracing,  while  the  fourth  record  may  be  taken  at  pleasure 
from  either  the  jugular  vein,  carotid  artery  or  apex  beat. 

Method  of  Operation. — ^The  cuff  M  is  attached  in  the  usual  manner 
to  the  upper  arm  and  pressure  applied  by  means  of  the  bulb  B  until 
the  pulse  disappears.  The  pressure  thus  applied  is  first  transmitted 
to  the  mercury  manometer  Q,  lifting  the  perforated  float  as  the 
mercurial  column  rises.  At  the  same  time  it  is  transmitted  to  the 
rubber  bulb  enclosed  in  the  glass  bulb  G  which  is  in  air-tight  con- 

•  Das  Verhalten  des  Blutdrucks  beim  Menschen  wahrend  der  Erholung  von 
Muskelarbeit,  Ztschr.  f.  klin.  Med.,  Ixx,  444. 

2  Criticism  of  the  Uskoff  Sphygmotonograph,  Arch.  Int.  Med.,  1912,  ix,  22. 


100     INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

nection  with  both  the  cuff  and  the  manometer.  With  the  handle 
of  the  cock  //  in  the  vertical  position,  the  air  in  the  glass  bulb  is 
expelled  through  the  cock  K^  which  is  automatically  opened  at 
the  same  time  as  K^. 

When  the  pulse  has,  by  application  of  sufficient  pressure,  dis- 
appeared the  cock  H  is  turned  in  the  direction  of  the  arrow,  which 
movement  connects  the  glass  bulb  G  with  the  outside  air  through 
an  exceedingly  small  opening,  and  the  pulsations  appear  because 
air-pressure  in  the  cuff  and  manometer  is  thus  slowly  relieved 
through  the  valve  V  and  is  divided  between  the  rubber  bulb  and 
the  air  in  the  glass  bulb  G.  The  pulsations  are  at  the  same  time 
transmitted  from  the  air  in  the  glass  bulb  G  by  means  of  the  third 
tabulature  in  connection  with  the  indicator  to  the  tracing  paper. 


Fig.  41. — Tracing  of  blood-pressure~made  with  the  Uskoff  apparatus.  The  upper 
tracing  (A)  represents  the  pressure  in  millimeters  of  mercury,  and  the  tracing  is  made 
while  the  pressure  is  reduced  from  200  mm.  to  50  mm.,  each  vibration  representing 
2  mm.  of  mercury  column,  with  the  one  vibration,  omitted  every  50  mm.  The  second 
tracing  (B)  represents  one  taken  from  the  carotid  artery  and  recorded  by  indicator 
2.  This  indicator  may  be  used  to  record  either  the  apex  beat  or  the  jugular  or  other 
vein  pulsations  at  will.  The  third  tracing  (C)  is  the  sphygmotonogram  or  the  tracing 
of  the  arterial  (brachial)  pulse  under  a  falling  pressure.  With  200  mm.  of  pressure 
this  indicator  traces  a  straight  line  because  of  the  total  obliteration  of  the  pulse. 
At  162  mm.  of  pressure  the  pulse  reappears  and  at  92  mm.  of  pressure  has  reached 
the  lowest  point  of  maximum  oscillation.  If  the  float  on  the  mercury  column  con- 
tinues to  sink,  the  internal  pressiu-e  is  shown  to  be  greater  and  the  vibrations  become 
smaller  and  smaller  because  of  the  elastic  layer  between  the  cuflf  and  the  artery,  until 
it  disappears  entirely.  This  tracing  taken  under  diminishing  pressure  constitutes, 
therefore,  an  accurate  record  of  both  the  diastolic  and  systolic  pressure. 

The  pressure  arising  from  compression  of  the  rubber  bulb  B 
is  ;also  transmitted  to  two  small  outlets  confronting  each  other 
on  the  top  of  the  manometer,  between  which  openings  the  per- 
forated float  passes  as  it  rises  and  falls  on  the  mercury  column. 
The  small  holes  in  the  float  are  arranged  1  mm.  apart  with  out- 
standing marks.  The  50  mm.  gradations  are  indicated  by  the 
omission  of  1  mm.  The  passage  of  the  air  current  through  the  small 
openings  and  through  the  corresponding  perforations  in  the  float 
operates  indicator  3,  and  thus  graphically  records  the  actual  press- 


INSTRUMENTS  FOR  GRAPHIC  REGISTRATION  101 

ure  in  millimeters  of  mercury  at  any  moment  throughout  the 
operation. 

Another  instrument  of  the  graphic  type  is  that  of  Silhermawn} 
(Fig.  42).  It  is  comprised  of  a  radial  and  a  brachial  cuff,  a  mercury 
manometer,  float,  revolving  drum  for  smoked  paper,  and  an  auto- 
matic registering  device.  The  latter  consists  of  a  vertical  arm 
from  which  comb-like  projections  extend.  These  projections  are 
regularly  spaced  at  intervals  corresponding  to  5  mm.  Hg.  in  the 
manometer.    When  the  kymographion  revolves  a  series  of  parallel, 


Fig.  42. — Silbermann's  tonograph:  B,  brachial  cuff;  D,  radial  cuff;  R,  radial 
pulse  recorder;  T,  time  marker;  F,  float,  indicating  height  of  mercury  in  manometer; 
C,  comb  to  mark  5  mm.  spacings  on  kymograph;  M,  driving  mechanism. 

horizontal  lines — like  a  ruled  page — are  drawn  on  the  smoked 
paper  upon  which  the  sphygmographic  tracing  is  recorded.  These 
parallel  lines  take  the  place  of  a  scale  on  the  manometer.  The 
instrument  is  also  supplied  with  a  time  marker,  recording  fifths 
of  a  second,  and  the  driving  mechanism  with  two  speeds. 

Method. — ^The  brachial  cuff  B  is  applied  to  the  arm,  inflated 
just  enough  to  bring  the  0  pressure  level  in  the  manometer  on  a 

1  Der  Tonograph,  Med.  Klinik,  August  30,  1908,  No.  35,  p.  1347.  Manufactured 
by  Oehmke,  21  Luisenstrasse,  Berlin. 


102    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

level  with  the  first  tooth  of  the  comb,  and  then  clamped  off.  The 
heavy,  double  cautery  bulb  is  now  inflated  to  its  maximum  capacity 
30  that  when  the  clamp  is  released  after  the  kymograph  is  set  in 
niotion  a  steady  and  continuous  rise  in  manometrical  pressure 
will  result.  The  radial  cuff  D,  consisting  of  a  small  rubber  capsule 
held  in  place  by  a  strap,  can  be  brought  under  different  degrees 
of  tension  by  means  of  a  screw.  When  applied,  this  is  so  adjusted 
as  to  produce  the  maximum  radial  oscillation.  It  is  used  as  an 
indicator  of  the  levels  at  which  with  a  rising  pressure  (1)  the  last 
pulse  wave  traverses  the  brachial  cuff  (systolic  pressure);  (2)  the 
first  maximum  oscillation  occurs  (diastolic  pressure).  Readings 
obtained  with  this  instrument  are  from  4  to  5  mm  Hg.  lower  than 


Fig.  43. — -Tracing  made  with  Silbermanu's  tonograph  showing  systolic  pressure, 
118  mm.;  diastolic  pressure,  65  mm. 

with  the  Riva-Rocci  method,  discrepancies  which  result  from  the 
weight  of  the  float  and  the  friction  produced  between  the  float 
recorder  and  the  smoked  paper.  As  this  error  is  a  constant  one 
the  author  suggests  setting  the  abscissa  line  on  a  level  with  the 
second  tooth  of  the  comb  (Fig.  43). 

Another  graphic  instrument  has  been  devised  by  Brugsch.^  It 
consists  of  a  U-shaped  manometer  and  a  revolving  drum  covered 
with  white  paper  ruled  in  centimeter  squares,  which  can  be  set 
at  any  level.  A  registering  float  superimposed  on  the  mercurial 
column  transmits  its  height  and  pulsations  directly  to  the  drum. 
The  latter  is  set  at  such  a  level  that  the  abscissa  of  the  centimeter 

*  Zur  Frage  der  Sphygmotonographie,  nebst  Beschreibung  eines  neuen  Sphygmo- 
tonographen,  Ztschr.  f.  Exp.  Path.  u.  Therap.,  May  30,  1912,  xi. 


Instruments  for  ghaphic  registration       103 

ruling  and  the  zero  point  of  the  mercury  correspond.  Thus  the 
actual  height  of  the  tracing  above  the  base  line,  multiplied  by  2 
(U-shaped  manometer)  gives  us  the  correct  reading.  The  brachial 
pulsations  are  transmitted  by  means  of  rubber  tubing  to  a  piston 
recorder  and  inscribed  by  means  of  ink  pens  upon  the  drum  below 
the  pressure  curve  (Fig.  44). 

A  more  elaborate  and  complicated  instrument,  based  on  the 
Erlanger  principle,  is  the  sphygmoturgograph  of  Muenzer^  (Fig. 
45).  The  tubing  S  connects  pump  P  with  cuff  M  and  is  inter- 
rupted by  stopcock  h  to  prevent  communication  with  the  glass- 


FiG.  44. — Brugsoh's  sphygmotonograph. 

enclosed  balloon  B,  until  this  is  desired.  The  tubing  T,  connects 
the  balloon  with  the  tambour.  When  air  is  pumped  into  the  system 
it  reaches  the  manometer  St,  the  cuff  M  and  the  balloon  B.  With 
the  cuff  applied  to  the  arm  and  sufficiently  inflated,  the  cock  h 
being  closed,  the  pulsations  are  transmitted  from  the  cuff  through 
the  balloon  to  the  k\Tnograph  upon  which  they  are  recorded.  The 
kymograph  is  supplied  with  two  speeds — a  slow  one  for  blood- 
pressure  tracings,  a  rapid  one  for  pulse  tracings — and  a  time  marker. 

1  Apparat.  z.  objektiver  Blutdnickmessung,  etc.,  Munchen.  med.  Wchnschr., 
1907,  xxxvii,  1809;  also  Ueber  Blutdnickmessung,  Ztschr.  f.  exper.  Path.  u.  Therap., 
1907,  iv. 


104    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

In  order  to  obtain  the  greatest  and  most  accurate  oscillations  it  is 
necessary  to  close  both  the  cocks  h  and  h'  in  order  to  exclude  the 


Fig.  45. — Muenzer's  sphygmoturgograph. 


Fig.  46. — Turgotonograph.     (Strauss-Fleischer.) 


INSTRUMENTS  FOR  GRAPHIC  REGISTRATION 


105 


pump  and  the  manometer,  since  in  recording  the  pulsations  only 
the  cuff  and  the  balloon  are  necessary. 

A  somethat  similar  instrument  has  been  designed  by  Fleischer,^ 
who,  however,  instead  of  using  the  glass-enclosed  balloon  to 
diminish  the  force  of  the  pulsations  between  the  cuft'  and  the  tam- 
bour, has  constructed  a  device  consisting  of  a  metal  cylinder  (ikf) 
enclosing  a  celluloid  cylinder  (Sch)  floated  on  a  layer  of  oil  (P).  The 
air  enters  from  the  cuff  through  the  tube  r  and  finding  no  means 


B 

Fig.  47. — A,  pen  used  for  recording  oscillations;  B,  tracing  made  with  the  Brugsch 
apparatus.     (Brugsch.) 

of  escape  imparts  its  pulsations  to  the  counterweighted  lever  G  at 
the  point  A,  whence  a  wire  (D)  again  transmits  the  motion  to  the 
aluminum  recording  needle  S.     (Figs.  48  and  49.) 

The  cuff  shown  in  the  accompanying  Fig.  49  is  used  for  the 
transmission  of  the  pulse.  It  consists  of  a  metallic  cylinder  L, 
the  upper  closed  end  of  which  is  perforated  by  a  tube  which  connects 
with  the  polygraphic  tambour.    Its  lower  end  is  closed  by  means 


1  Ueber  turgotonographische  Pulsdruckbestimmung,  Berl.  klin.  Wchnschr.,  1907, 
No.  35,  1108. 


106    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

of  a  "lense"  consisting  of  a  rubber  capsule  G  filled  with  glycerin. 
The  cuff  is  held  in  place  by  the  straps  11  and  its  pressure  can  be 


Fig.  48. — Strauss-Fleischer  device  for  damping  the  force  of  the  pulse  wave. 

adjusted  by  the  thumb-screw  Sy.  With  this  cuff  tracings  can  be 
made  of  most  of  the  superficial  arteries,  including  the  digital  and 
temporal  vessels.^ 

n 


<  Fig.  49. — Cufif  used  with  Fleischer  instrument. 

Bussenius's  instrument  for  the  graphic  registration  of  the  blood- 
pressure  ingeniously  eliminates  the  necessity  of  a  driving  mech- 
anism for  the  strip  of  smoked  paper  in  the  following  manner:  A 
narrow  strip  of  paper  supported  in  an  upright  slot,  falls  by  gravity 

■  Zur  Methodik  der  Pulschreibung,  Berl.  klin.  Wchnschr.,  1909,  xlvi,  2141. 


INSTRUMENTS  FOR  GRAPHIC  REGISTRATION  107 


Fig.  50. — Busaenius's  sphygmotonograph. 


108    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

past  the  oscillating  tambour.  The  descent  of  the  strip  is  delayed 
by  the  displacement  of  glycerin  around  a  metallic  plunger,  which 
is  so  graded  that  the  strip  will  fall  1  cm.  per  second.  Both  systolic 
and  diastolic  pressures  can  be  estimated  with  this  instrument;  in 
fact,  two  tracings  may  be  ma^e  consecutively  on  the  same  strip 
and  used  to  control  each  other  (see  Fig.  50).  It  is  merely  essential 
that  the  beginning  of  the  tracing  corresponds  with  0  mm.  pressure 
in  the  manometer.^ 

Wybauw's  instrument^  is  essentially  a  modification  of  Erlanger's. 
He,  however,  uses  a  divided  cuff  (4  and  9  cm.  broad)  which  yields 
a  more  accurate  systolic  reading,  since  the  impactions  of  the  pulse 
wave  against  the  upper  part  of  the  cuff  are  not  transmitted  to  the 
tambour.    The  height  of  the  pressure  is  not  automatically  recorded. 

IV.  Visual  (Oscillatory)  Methods. — Instruments  of  this  type  are 
constructed  in  association  with  different  kinds  of  oscillating  devices 
which  indirectly  magnify  the  fluctuations  of  the  mercurial  column, 
or  otherwise  render  the  pulsations  of  the  cuff  more  readily  percep- 
tible. The  oscillatory  method  is  more  satisfactory  for  the  deter- 
mination of  the  diastolic  pressure  than  the  method  of  palpation, 
but  less  so  than  that  of  auscultation. 

D.  OSCILLATORY  INSTRUMENTS. 

The  instruments  based  on  this  method  may  be  divided  into :  (I) 
Those  which  register  the  height  of  the  pressure,  and  the  degree 
of  excursion  by  different  devices.  (II)  Those  which  indicate  these 
two  factors  upon  the  same  dial.  The  former  usually  render  too  high 
systolic  readings.  The  diastolic  pressure  as  indicated  by  type  II  is 
practically  similar  to  that  obtained  by  palpation.  In  type  I  the 
readings  are  somewhat  higher.^ 

Class  I. — The  apparatus  of  Bing*  (Fig.  51)  consists  of  a  man- 
ometer, pump,  two  cuffs  and  a  colored  liquid  indicator  somewhat 
similar  to  that  devised  by  PaP  (Fig.  52).  Here  the  lower  cuff  b, 
substituting  the  finger  in  the  palpatory  method,  transmits  such 
pu;lsations  as  pass  the  upper  cuff  a  to  the  colored  oil  droplets  in 
the  indicator  c.     The  pressure  on  either  side  of  the  oil  droplets 

*  Manufactured  by  W.  Oehmke,  Berlin. 

2  Graphische  Blutdruckbestimmungen  bei  unregelmassiger  Herzwirkung,  Ztschr. 
f.  klin.  Med.,  1911,  Ixxiii,  204-220. 

'  Cordier  and  Rebattu:    Arch.  d.  mal.  du  occur,  1911,  iv,  737. 

*  Ein  Apparat.  z.  Messung  des  Blutdrucks  bei  Menschen,  Berl.  klin.  Wchnschr., 
1907,  No.  22;  Blutdruckmessungen  bei  Menschen,  Berl.  klin.  W'chnschr.,  1906,  No.  52. 

s  Ein  Sphygmoskop.  z.  Bestimniung  des  Pulsdruckes,  Zentralbl.  f.  inn.  Med., 
February,  1906,  No.  15. 


OSCILLATORY  INSTRUMENTS 


109 


being  equalized,  a  very  slight  pulsation  in  the  cuff  produces  an 
extensive  oscillation  in  the  sphygmoscope. 


Fig.  51. — Bing's  sphygmomanometer:  a,  mensurating  cuff;  b,  occlusive  indicating 
cuff;  c,  sphygmoscope;  d,  control  value;  e,  pump;  /,  manometer;  g,  manometer 
escapement;  h,  sphygmoscope  escapement. 


Fig.  52. — The  sphygmoscope.     (Pal.) 


110    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

The  values  obtained  average  10  mm.  higher  than  with  the  Riva- 
Rocci  method,  chiefly  owing  to  the  fact  that  in  the  last-named 
procedure  peripheral  contraction  of  the  brachial  artery  may  cause 
a  local  elevation  in  pressure  without  affecting  the   rest  of  the 


IMPROVEMENTS  FOR 
FACILITATING  THE  TAKING  OF 
MINIMUM  DIASTOLIC  PRESSURE 


_T0  CUFF 
.VENT 


v_,.TO  COMPRESSION  EULD 


Fig.  53. — Fcdde's  oscillometer.  This  instrument  has  been  modified  by  R.  L. 
Hoobler  by  using  two  cuffs  with  a  stopcock  connection  between  them,  in  circuit  with 
the  pith-ball  indicator.  This  permits  the  reading  of  the  systolic  as  well  as  the  diastolic 
pressure,  and  yields  better  results  in  infants  (Nicholson).  This  oscillatory  device 
may  be  used  in  conjunction  with  many  types  of  instruments.  It  is  furnished  (at  an 
extra  cost)  with  the  Nicholson  and  the  Faught  sphygmomanometers. 


OSCILLATORY  INSTRUMENTS 


111 


systemic  circulation.     This  factor  is  said  to  be  obviated  in  the 
Bing  apparatus  by  the  second  cuff.^ 

The  Sphygmoscope  (Pal). — ^The  capillary  tube  C-C,  containing 
a  few  drops  of  colored  petroleum,  communicates  with  the  tube 
A-B,  the  left  arm  of  which  (A-H)  is  smaller  in  caliber  than  the 
right  {H-B).     yl  is  a  two-way  cock  enabling  communication  to 


Fig.  54. — Widmer's  oscillometer. 


be  established  (through  3  and  4)  with  two  manometrical  cuffs, 
e.  g.,  one  on  the  arm,  another  on  the  finger.  B  is  an  escapement 
cock.  The  tube  2  communicates  with  a  manometer,  while  1  is 
connected  with  the  pump  (Fig.  52). 

'  V.  Worth  has  devised  a  somewhat  similar  instrument,  equipped  with  an  oscillator 
which  transmits  the  radial  pulsations  from  a  rubber  glycerin-containing  pelotte 
which  can,  however,  only  be  used  for  the  systolic  oscillations.  Ueber  d.  Messung  d. 
Systolischen  Blutdrucks  auf  Optischen  Wegc,  Miinchen.  med.  Wchnschr.,  1910, 
Ivii,  1286.     Manufactured  by  Oehmkc,  Berlin,  Luisenstrasse,  21,  N.  W. 


112    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

Method. — After  the  pressure  has  been  raised  in  the  cuff,  //  is 
turned  45  degrees,  thus  closing  all  communications  through  the 
four-way  cock,  whereupon  oscillations  of  pressure  are  manifest  in 
the  capillary  tube  C-C. 

Widmers  Oscillomanometer. ^-The  first  full  oscillation  (systolic 
pressure),  and  the  maximum  oscillation  (diastolic  pressure),  are 
indicated  upon  the  graduated  scale,  while  the  actual  pressure  is  read 
from  the  mercury  manometer^  (Fig-  54). 

Another  instrument  based  on  the  same  principle  is  the  "sphygmo- 
signal"  of  Vaquez.^  Here  again  two  cuffs  are  employed,  but  with 
a  metallic  manometer  and  a  different  form  of  indicator  (Fig.  55). 


J^ 


Fig.  55. — Vaquez's  sphygmo-signal. 

E.  ANEROID  INSTRUMENTS. 

Class  II. — The  most  accurate  aneroid  instrument  at  present 
available  is  unquestionably  that  of  Pachon.^  It  has  recently  been 
highly  commended  by  Bachmann,^  who  has  made  extensive  studies 
regarding  its  accuracy. 

"In  estimating  the  systolic  pressure  it  is  customary  to  observe 
the  disappearance  of  the  arterial  pulsation  at  the  radial  (method 
of  Riva-Rocci),  occasionally  at  the  brachial  below  the  cuff,  at 

1  Manufactured  by  W.  Oehmke,  Berlin. 

*  For  further  description  see  Vaquez:   Soc.  de  Biologic,  1908. 

'  Oscillomfetre  sphygmanometrique  h  grande  sensibilite  et  h  sensibilite  constante, 
Comptes  rendus  de  Soc.  biol.,  Ixvi,  776;  also  Paris  M6dicale,  1911,  xxxi,  122. 
Manufactured  by  C.  Verdin,  rue  Linn6  17,  Paris.  A.  H.  Thomas  &  Co.,  Philadelphia 
agents. 

*The  Measurement  of  the  Arterial  Tension  in  Man,  New  York  Med.  Jour., 
February  4,  1911. 


ANEROID  INSTRUMENTS 


113 


any  rate  always  at  some  distance  from  the  point  of  compression. 
This  method  of  applying  Marey's  principle  is  essentially  faulty 
and  the  results  obtained  are  necessarily  erroneous.  Indeed,  it  can 
be  shown  that  while  the  pulse  has  disappeared  at  the  radial  there 
is  a  pronounced  pulsation  in  that  portion  of  the  brachial  artery 
under  compression.  Pachon,  who  demonstrated  this  fact  by  means 
of  his  instrument  (to  be  described  presently)  and  by  the  sphygmo- 
signal  of  Vaquez,  gives  the  following  theoretic  explanation  of  his 
experimental  finding : 

"  The  pulse  wave  has  its  origin  in  the  contraction  of  the  ventricle 
and  represents  a  certain  amount  of  kinetic  energy.  This  wave 
of  pressure  spreads  from  the  root  of  the  aorta  to  the  end  of  the 
arterial  system  and  in  so  doing  loses  energy  little  by  little,  owing 


Fig.  56. — The  Pachon  sphygmometric  oscillometer. 


to  friction  against  the  sides  of  the  vessels.  As  the  resulting  dis- 
tention of  the  arterial  walls  is  normally  extremely  slight  (Poiseuille), 
very  little  external  work  is  performed  by  the  pulse  wave.  If, 
however,  a  segment  of  an  artery  is  compressed  so  that  a  portion 
of  its  internal  pressure  is  counter-balanced,  that  segment  will  yield 
to  a  greater  extent  to  the  distending  force  of  the  pulse  wave  and 
the  vessel  wall  will  begin  to  move.  In  other  words,  external  work 
will  be  done.  The  compression  may  be  such  that  the  extent  of 
the  movement  of  the  vessel  wall  (hence  the  amount  of  work  done 
by  the  pulse  wave)  will  exactly  balance  the  amount  of  energy 
possessed  by  the  wave.  At  this  moment  the  pulse  wave  is  entirely 
utilized  in  performing  mechanical  work;  it  is  therefore  absorbed  at 
this  point  and  no  pulsation  can  be  felt  below  it.  The  blood  flow, 
however,  has  not  been  interrupted,  the  intermittent  flow  has  merely 
8 


114    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

been  changed  into  a  continuous  one.  This  explains  why  wide  cuffs, 
with  a  larger  area  for  the  absorption  of  the  pulse  wave,  give  lower 
figures  than  narrow  ones.  It  serves  to  explain  also  why  the  arterial 
pressure  in  man  appears  so  low  in  comparison  to  that  observed  in 
the  other  mammalia.  Bencziir  reached  practically  the  same  con- 
clusions by  the  combined  use  of  the  Recklinghausen  and  Gartner 
instruments"  (Bachmann). 

Marey's  principle  for  the  determination  of  the  minimum  or 
diastolic  pressure  has  been  more  correctly  applied,  in  that  the 
oscillations  of  the  compressed  artery  are  transmitted  directly  to 
the  instrument  and  their  amplitude  noted.  As  stated  by  Pachon, 
however,  the  instrument  which  is  to  reproduce  these  pulsations 


Fig.  57. — Diagram  showing  the  relation  of  the  essential  parts  of  Pachon's  sphygmo- 
metric  oscillometer.  (After  Pachon.)  Bis  a  rigid  metallic  box  hermetically  sealed  and 
containing  in  its  interior  an  aneroid  drum  (o)  with  which  is  connected  the  lever  n. 
M  is  an  aneroid  manometer  which  indicates  the  level  of  the  pressure  in  the  entire 
system.  The  box,  manometer,  aneroid  drum  o,  and  the  cuff  are  normally  in  free 
communication  by  means  of  the  tubes  d,  e,  /.  The  pressure  can  be  raised  in  the 
system  by  means  of  the  pump  P;  it  can  be  lowered  by  allowing  the  air  to  escape  by 
unscrewing  the  valve  s.  The  cuff  and  the  aneroid  a  can  be  cut  off  from  the  rest  of 
the  apparatus  by  compressing  the  rubber  tube  d  by  means  of  the  compressor  c 
(called  separator  by  Pachon).     (Bachmann.) 


must  have  both  a  great  and  a  constant  sensibility.  The  mercury 
manometer  has  naturally  a  constant  sensibility,  but  owing  to  the 
inertia  of  the  mercury  this  sensibility  is  but  slight,  surely  not 
sufficient  to  enable  one  to  compare  differences  in  the  amplitude 
oi'  oscillations  at  various  levels  of  pressure.  Everyone  who  has  used 
the  mercury  manometer  for  the  determination  of  the  diastolic 
pressure  is  impressed  with  its  imperfections  for  this  purpose.  A 
few  investigators  have  sought  to  overcome  this  defect  by  placing  an 
elastic  bag  in  connection  with  the  cuff,  through  which  combination 
the  arterial  pulsations  are  taken  up  and  transmitted  by  appropriate 
means  to  a  tambour  to  be  magnified  and  graphically  recorded 
(Erlanger,  Uskoff).      The  first  objection  to  this  method  is  that  the 


ANEROID  INSTRUMENTS  115 

bag  cannot  be  made  sensitive  on  account  of  the  relatively  high 
pressure  to  which  it  must  be  subjected.  The  second  objection  is 
that  such  a  bag  has  not  a  constant  sensibility  at  various  pressure 
levels.  The  amplitude  of  its  oscillations  will  be  smaller  the  greater 
its  state  of  tension  (distention),  the  force  of  the  oscillations  remain- 
ing the  same.  It  will  therefore  lead  to  error  to  compare  the  ampli- 
tude of  oscillations  obtained  at  various  pressure  levels. 

All  these  objections  have  been  removed  in  the  simple  and  ingen- 
ious instrument  devised  recently  by  Pachon.  The  main  features 
in  the  construction  of  this  instrument,  which  he  names  a  sphygmo- 
metric  oscillometer,  can  best  be  understood  by  reference  to  Fig.  57. 

The  position  of  the  aneroid  a  is  in  the  interior  of  the  box,  and 
the  free  communication  of  the  interior  of  the  same  manometer 
with  the  box  and  the  cuff  have  solved  the  problem  of  devising  an 
instrument  which  would  have  both  a  great  and  a  constant  sensibility 
at  any  pressure  level.  By  reason  of  this  arrangement  the  same 
pressure  is  exerted  at  all  times  on  the  external  as  on  the  internal 
surfaces  of  the  drum  a;  hence  this  drum  is  always  in  a  position  of 
rest  or  zero  tension,  except  when  by  compressing  c  the  cuff  is  placed 
in  direct  communication  with  the  interior  of  the  drum  and  any 
change  of  pressure  within  the  cuff  may  then  act  upon  it.  These 
changes  of  pressure  due  to  the  pulsations  of  the  artery  are  normally 
very  slight,  so  that  the  drum  a  could  be  made  of  relatively  thin 
metal,  hence  very  sensitive.  This  sensibility  will  always  be  the 
same,  no  matter  what  the  level  of  the  pressure  around  the  arm  may 
be,  since  it  always  takes  up  the  pressure  changes  in  the  cuff  by 
starting  from  a  state  of  no  tension. 

"In  using  the  instrument  the  cuff  is  placed  around  the  arm  in 
the  usual  manner.  Air  is  pumped  into  the  system  until  the  pressure 
is  well  above  the  normal  arterial  pressure.  The  amount  of  the 
pressure  is  read  from  manometer  M.  The  observer  now  confines 
his  attention  to  the  manipulation  of  valve  s  and  compressor  c, 
using  preferably  one  hand  only  in  order  to  insure  free  opening 
of  the  tube  d  when  valve  *  is  opened  and  closed.  If  on  compressing 
c  the  hand  n  does  not  oscillate,  valve  s  is  opened  and  the  pressure 
allowed  to  fall  one-half  to  one  centimeter;  c  is  again  pressed  upon 
and  the  hand  n  observed.  This  maneuver  is  repeated  until  oscilla- 
tions of  the  hand  n  to  the  extent  of,  say,  one  degree  of  the  dial  are 
shown.  This  moment  indicates  the  return  of  the  pulse  at  the  point 
compressed,  and  therefore  the  maximum  or  systolic  pressure  there. 
This  is  read  on  manometer  M.  To  determine  the  minimum  or 
diastolic  pressure,  the  pressure  in  the  system  is  lowered  in  the 


116     INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

manner  explained  above  and  the  compressor  c  manipulated  between 
each  lowering  of  pressure;  at  the  same  time  the  hand  n  is  observed 
and  at  the  moment  its  excursions  are  greatest  the  level  of  diastolic 
pressure  has  been  reached,  and  can  be  read  on  manometer  M.  This 
is  the  most  satisfactory  instrument  I  have  seen  for  the  determination 
of  the  diastolic  pressure;  the  oscillations  are  large  and  the  moment 
of  greatest  amplitude  is  clear  cut,  for  both  immediately  before  and 
immediately  after  this  moment  the  oscillations  are  noticeably 
smaller." 


Fig.  58. — Diagram  illustrating  the  construction  of  the  Tycos  aneroid. 

"The  determination  of  the  systolic  pressure  in  such  instruments 
is  a  vexed  question.  Erlanger  obtains  small  pulsations  with  his 
instrument,  as  shown  by  the  movements  of  the  lever,  before  the 
true  systolic  level  has  been  reached.  This  he  attributes  to  the 
'hydraulic  ram  action'  of  the  pulsating  proximal  stump  of  the 
artery  against  the  edge  of  the  cuff.  Pachon  now  uses  a  cuff  adapted 
to  the  wrist,  where,  on  account  of  the  small  size  of  the  vessels,  and 


ANEROID  INSTRUMENTS 


117 


the  fairly  thick  edge  of  the  cuff,  the  danger  of  this  source  of  error 
should  be  greatly  minimized.  The  writer  observed  that  an  oscilla- 
tion of  the  hand  n,  equivalent  to  one  degree  of  the  scale,  indicates 
the  return  of  the  pulse  at  the  point  compressed,  as  controlled  by 
the  palpation  of  the  artery  under  similar  conditions.  To  determine 
this  point  a  cuff  is  placed  around  the  upper  arm  and  one  around 
the  wrist.    The  two  cuffs  are  connected  with  the  Pachon  instrument 


Fig.  59. — Showing  the  construction  of  the  Faught  aneroid. 


by  means  of  a  Y-tube;  a  stopcock  is  placed  in  the  course  of  each 
tube  coming  from  the  cuffs.  A  pressure  is  put  around  the  wrist 
equal  to  the  diastolic  pressure  at  this  point.  When  a  pressure  is 
applied  around  the  brachial  equal  to  the  systolic  pressure  and  the 
stopcocks  and  compressor  suitably  manipulated,  no  pulsation  is  seen 
at  the  wrist.  The  pressure  must  be  lowered  considerably  around 
the  brachial  before  a  pulsation  is  indicated  at  the  wrist.  If  now 
the  radial  cuff  is  removed  and  the  brachial  systolic  pressure  esti- 


118    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

mated  by  the  ordinary  method  of  palpation  of  the  radial  artery, 
it  will  be  observed  that  the  pulse  is  felt  when  the  pressure  around 
the  brachial  is  at  the  same  level  as  when  the  indicator  of  the  Pachon 
instrument  showed  an  oscillation  of  approximately  one  degree, 
when  it  was  in  relation  with  ^he  radial  cuff.  The  following  table 
will  show  the  result  of  a  few  observations"  (Bachmann) : 


Age. 

Systolic  pressure  in 

brachial  artery  (Pachon) 

In  mm.  Hg. 

27 

130 

26 

125 

33 

130 

Pressure  in  brachial  cuff 
at  which  pulse  appears 

at  wrist. 
(Pachon.)          (Tactile.) 

Diastolic  pressure 
at  wrist  (Pachon). 

105                 105 

80 

105                 105 

90 

110                 110 

90 

Fig.  60. — An  aneroid  instrument  in  use.     (Auscultatory  method.)' 

The  systolic  readings  with  the  "oscillometer"  are  from  20  to 
40  mm.  Hg.  higher  than  with  the  Stanton  apparatus  (Riva-Rocci 
method).  In  the  diastolic  readings  there  is  less  discrepancy.  This 
instrument  is  well  suited  to  ward  or  office  work.  It  is  free  from 
error  due  to  personal  equation,  yields— especially  for  the  diastolic 
pressure — satisfactory  results,  and  is  quickly  manipulated;  but 
its  weight  militates  against  its  ready  transportation,  and  it  is  open 
to  the  objection  which  applies  to  all  aneroids,  namely,  the  necessity 
of  occasional  standardization. 

A  number  of  compact  little  blood-pressure  instruments  fitted 
with  aneroids  are  on  the  market.    These  instruments  consist  of  a 

'  Manufactured  by  G.  P.  Pilling  &  Co.,  Philadelphia.  A  somewhat  similar 
instrument — the  Rogers  "Tycos"  sphygmomanometer — is  manufactured  by  the 
Taylor  Instrument  Co.,  Rochester,  New  York. 


ANEROID  INSTRUMENTS  119 

chamber  of  corrugated  metal  which  expands  under  pressure  and 
imparts  its  movement  to  a  calibrated  dial.  They  can  be  carried 
in  the  pocket  and  are  free  from  all  danger  of  spilling  the  mercury, 
etc.  Breakage  is  also  less  likely.  They  give  readings  sufficiently 
accurate  for  clinical  work,  but  they  have  to  be  standardized  from 
time  to  time,  as  they  are  apt  to  get  out  of  adjustment.  Unless  the 
readings  obtained  are  occasionally  checked  up  with  an  accurate 
manometer,  one  can  never  be  sure  that  the  results  are  not  erroneous. 
What  has  already  been  said  regarding  the  size  and  character  of 
the  cuff  of  course  applies  equally  to  this  type  of  apparatus.  I 
have  obtained  very  satisfactory  service  from  the  Sanborn  aneroid, 
an  instrument  recently  put  on  the  market.^ 

Standardization  of  the  Aneroid. — The  accuracy  of  the  aneroid 
can  be  readily  tested  with  an  ordinary  mercury  manoiyieter,  if  a 
three-way  stopcock  is  used  to  connect  the  two  manometers  with 
a  pump.  The  pressure  is  raised  5  mm.  at  a  time  and  the  readings 
indicated  by  the  two  instruments  are  compared,  thus  showing  the 
amount  of  correction  which  must  be  applied  to  the  aneroid  at  a 
given  level. 

The  von  Recklinghausen  tonometer,^  an  instrument  which  has 
found  considerable  favor  in  Germany,  is  based  on  the  principle 
"first  introduced  into  physical  science  by  Bourdon  and  later 
incorporated  into  the  kymograph  of  Fick,  that  if  a  very  shallow, 
curved,  elongated  air  chamber  is  fixed  at  one  end  of  the  arc  with  a 
pressure  apparatus,  while  the  other  is  closed,  any  increase  of  pressure 
will  be  made  manifest  by  a  flattening  or  elongation  of  the  arc, 
thereby  imparting  a  certain  movement  to  the  end  that  is  free. 
By  a  very  simple  device  this  movement  of  the  air  chamber  is  com- 
municated to  an  axis  on  which,  guarded  by  a  hair-spring,  there 
is  fastened  a  long  needle  whose  tip  is  made  to  move  along  a  gradu- 
ated scale  previously  standardized,  the  final  figures  being  read 
off  from  the  dial."  The  pressure  which  is  supplied  by  a  long-stroke 
bicycle  pump  is  transmitted  from  a  standard  cuff  to  the  dial,  the 
graduations  of  which  are  equivalent  to  centimeters  of  water  (Figs, 
61  and  62). 

It  is  for  several  reasons  desirable  that  water  should  be  adopted 
as  a  standard  for  measurement  rather  than  mercury,  and  possibly 
this  will  sooner  or  later  come  to  pass.    First  of  all,  pressure  values 

'  Manufactured  by  the  Sanborn  Company,  79  Sudbury  Street,  Boston,  Mass. 
Sells  for  about  one-half  the  price  of  other  aneroid  instruments. 

2  Unblutige  Blutdruck  Messung,  Deutsch.  Arch.  f.  exp.  Path.  u.  Phar.,  1906,  Iv. 
Manufactured  by  C.  &  E.  Streisguth,  Strassburg.  A.  H.  Thomas  &  Co.,  Philadelphia, 
agents. 


120    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

can  be  directly  translated  into  grams;  second,  water  and  blood 
have  nearly  the  same  specific  gravity;  so  that  calculations  can 


Fig.  61. — The  von  Recklinghausen  tonometer:   A,  cuff;  B,  pump;  C,  tonometer 

dial. 


Fig.  62. — Tonometer. 


readily  be  made  as  to  differences  in  pressure  at  different  levels 
of  the  body  by  simply  measuring  the  difference  in  height  in  centi- 


ANEROID  INSTRUMENTS 


121 


meters,  e.  g.,  blood-pressure  at  cardiac  level  140,  at  level  of  spleen 
140-20=120. 

Water  having  less  inertia  than  mercury,  and  being  used  as  a 
unit  in  many  other  connections,  would  undoubtedly  be  more  desir- 
able as  a  standard  for  blood-pressure.  Unfortunately,  however, 
nearly  all  blood-pressure  readings  have  been  made  with  mercury, 
so  that  not  only  is  nearly  all  the  literature  based  on  this  standard, 
but  we  have  come  to  think  of  blood-pressure  in  millimeters  of 
mercury.  A  transposition  of  values  from  millimeters  Hg.  to 
centimeters  H2O  is  not  readily  made  without  reference  to  a  special 
table.  This  is  one  reason  why  the  instrument  has  never  found  favor, 
in  this  country  at  least.    It  is  perhaps  a  pity,  but  we  are  confronted 


Fig.  63. — The  new  von  Recklinghausen  tonometer. 


by  a  fact.  Another  reason  lies  in  the  construction  of  the  instrument. 
It  measures  tension  by  means  of  a  metallic  spring  which  perhaps 
even  more  often  than  in  the  case  of  aneroids  requires  "control" 
and  occasional  correction  to  insure  accurate  readings. 

The  systolic  pressure  as  recorded  with  this  instrument  is  slightly 
above  the  actual  pressure.  The  diastolic  pressure,  especially  if 
the  pulse-pressure  be  large,  is  too  low.  Strassburger^  si:.:gests  that 
observations  be  based  both  on  oscillation  and  on  palpation;  and 
further,  that  not  only  the  extent  of  the  excursion  be  used  as  a  cri- 
terion of  the  minimum  pressure,  but  also  the  point  at  which  the 
needle  begins  to  "hesitate"  and  to  "tremble."    He  believes  that 

*  Weitere  Untersuchungen  u.  d.  Messung  d.  diastoh"schen  Blutdruckes  beim 
Menschen,  Deutsch.  med.  Wchnschr.,  1909,  xxxiv,  56  and  100. 


122    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

in  this  manner  the  error  due  to  the  arterial  elasticity  (which  varies 
in  individuals,  and  for  different  degrees  of  pressure),  as  well  as  that 
resulting  from  partial  loss  of  pulsation,  due  to  imperfect  transmis- 
sion from  the  cuff,  may  be  mutually  controlled. 

The  Recklinghausen  instrument  has  recently  been  modified, 
making  it  smaller  in  bulk  (21  by  9  cm.,  weighing  f  kg.)  and  more 
readily  transportable.  It  is  also  supplied  in  another  modification 
for  office  use,  with  a  good-sized  compressed-air  tank,  so  that  very 
rapid  inflation  of  the  cuff  is  made  possible  by  the  release  of  a  screw- 
valve,  and  repeated  estimations  may  be  made  without  renewing 
the  air  supply  in  the  tank.  Care  must  of  course  be  exercised  when 
releasing  so  high  a  pressure  lest  the  limits  of  the  instrument  be 
overstepped  and  the  metallic  spring  be  thus  permanently  damaged^ 
(Fig.  62). 

Tables  of  Relative  Values. 
To  convert  centimeters  water  into  millimeters  Hg. 


Cm. 
w. 

Mm 
Hg 

i. 

Cm. 
w. 

Mm. 
Hg. 

Cm. 
w. 

Mm. 
Hg. 

Cm. 
w. 

Mm. 
Hg. 

Cm. 
w. 

Mm. 
Hg. 

1 

1 

10 

7 

110 

81 

210 

155 

310 

229 

2 

1 

20 

15 

120 

89 

220 

162 

320 

236 

3 

2 

30 

22 

130 

96 

230 

170 

330 

244 

4 

3 

40 

30 

140 

103 

240 

177 

340 

251 

5 

4 

50 

37 

150 

111 

250 

185 

350 

258 

6 

4 

60 

44 

160 

118 

260 

192 

360 

266 

7 

5 

70 

52 

170 

125 

270 

199 

370 

273 

8 

6 

•80 

59 

180 

133 

280 

207 

380 

280 

9 

7 

90 

66 

190 

140 

290 

214 

390 

288 

10 

7 

100 

74 

200 

148 

300 

221 

400 

295 

To  convert  millimeters 

1  Hg.  into  centimeters  water. 

Nm. 
Hg. 

Cm. 
w. 

Mm. 
Hg. 

Cm. 
w. 

Mm. 
Hg. 

Cm. 
w. 

Mm. 
Hg. 

Cm. 
w. 

1 

1 

10 

14 

110 

149 

210 

285 

2 

3 

20 

27 

120 

163 

220 

298 

3 

4 

30 

41 

130 

176 

230 

312 

4 

5 

40 

54 

140 

190 

240 

325 

5 

7 

50 

68 

150 

203 

250 

339 

6 

8 

60 

81 

160 

217 

260 

352 

7 

9 

70 

95 

170 

230 

270 

366 

8  11  80  108  180  244  280  379 

9  12  90  122  190  257  290  393 
10           14                   100           136                     200             271                     300             407 

The  Potain  instrument  has  never  found  favor  in  this  country. 
It  is  generally  and  justly  regarded  as  inaccurate,  partly  on  account 
of  its  construction  and  largely  on  account  of  its  application.  It 
is  still  frequently  used  in  France,  however,  with  the  idea  of  com- 
paring the  pressure  in  different  arteries — radial,  temporal,  dorsalis 

'v.  Recklinghausen,  H.:  Neue  Apparat.  z.  Messung  des  arteriellen  Blutdrucks 
beim  Menschen,  Miinchen.  med.  Wchnschr.,  1913,  Ixi,  869. 


ANEROID  INSTRUMENTS  123 

pedis,  etc.  The  pressure  required  to  obliterate  the  pulse  is  applied 
directly  over  the  artery,  the  compression  being  exerted  upon  the 
pelotte  with  the  fingers.  Thus  it  is  very  easy  to  exert  the  pressure 
mainly  against  the  tissues  and  but  slightly  if  at  all  upon  the  artery. 

Francois  Frank^  has  designed  an  instrument  (sphygmopalpeur) 
for  the  transmission  of  arterial  or  venous  pulsations  without  circular 
fixation,  and  recommends  its  use  in  connection  with  the  Potain 
sphygmomanometer.  It  consists  of  a  Marey  tambour  which  is 
attached  to  an  upright  stand  through  a  series  of  levels  and  joints 
so  that  it  can  be  set  at  any  angle  or  direction,  the  pressure  exerted 
by  it  varied  at  will.  Contrary  to  the  usual  findings,  he  obtained 
higher  readings  than  with  the  Riva-Rocci  instrument,  a  fact  which 
he  explains  as  follows: 

"The  Potain  apparatus  acts  only  on  the  radial  artery,  while  the 
method  of  circular  compression  by  producing  venous  stasis  reduced 
the  amplitude  of  the  arterial  pulse  and  has  the  effect  of  counter- 
pressure,  thus  yielding  too  low  a  reading." 

The  sphygmomanometer  of  Bouloumie  consists  of  a  combina- 
tion of  the  Potain  and  the  Gartner  apparatus.  It  has  been  used 
in  an  effort  to  study  the  relationship  of  arterial  and  capillary 
pressure.^ 

V.  Subjective  Method. — ^The  subjective  sensations  of  the  patient 
may  also  be  used  to  determine  the  systolic  and  diastolic  readings. 
With  the  cuff  and  manometer  applied  in  the  usual  manner  the 
patient  is  told  to  notice  the  onset  of  throbbing  in  the  arm  below 
the  cuff — this  indicating  the  systolic  pressure.  The  disappearance 
of  the  pulsatory  sensations  corresponds  to  the  diastolic  pressure. 
Quite  accurate  readings  may  thus  be  sometimes  attained,  but  the 
procedure  introduces  a  considerable  and  quite  unnecessary  amount 
of  the  personal  equation,  and  is  therefore  rarely  employed. 

Francois  Frank'  in  contrasting  the  findings  of  the  subjective 
method  with  those  obtained  by  the  Gartner  instrument,  found 
that  the  two  phenomena  (recoloration  and  sense  of  pulsation), 
although  identical  as  regards  the  height  of  manometric  pressure, 
are  not  so  as  regards  time  when  compared  to  the  beginning  of  the 
elevation  of  a  volumetric  curve,  there  being  a  temporal  difference 
of  from  four  to  six  seconds  between  the  two.  This  emphasizes  the 
importance  of  allowing  pressure  to  fall  slowly.    He  suggests  that 

1  Compt.  rend.  Soc.  de  biol.,  1909,  Ixviii,  525;  Soc.  biol.,  Paris,  July  25,  1908,  p.  226. 

*  Bouloumie's  instrument  described:  Amblard:  Th^se  de  Paris,  1907,  No.  261, 
p.  51. 

'  La  sphygmomanometric  digitale  par  le  precede  de  Gaertner  avec  et  sans  anemie 
prealable,  etc.,  Compt.  rend.  Soc.  de  biol.,  February  5,  1910,  p.  234. 


124    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

the  pulsatile  phenomenon,  which  manifests  itself  later  than  the 
beginning  of  recoloration,  indicates,  when  at  its  maximum,  the 
minimum  pressure  in  the  collateral  arteries  of  the  fingers;  while 
the  recoloration  and  the  initial  swelling  is  the  index  of  the  maximum 
pressure  of  the  arterioles.  He  finds  that  the  maximal  digital  arterial 
pressure  is  often  approximately  two-thirds  that  of  the  radial  press- 
ure, although  this  relationship  is  by  no  means  a  constant  one. 

Methods  of  estimating  pressure  based  on  subjective  sensations 
are  entirely  too  inaccurate  to  be  of  much  use.  This  applies  no  less 
to  recent  refinements  than  to  the  method  suggested  by  von  Frey, 
which  consisted  in  submersion  of  the  arm  in  mercury  and  the  meas- 
urement of  its  depth  to  the  point  at  which  the  greatest  pulsation 
was  felt. 

Comparative  Values. — The  palpatory  (Riva-Rocci)  method  yields 
results  which  are  on  the  average  7.5  mm.  Hg.  higher  for  every  100 
mm.  Hg.  than  the  actual  intra-arterial  pressure,  and  5  per  cent, 
lower  readings  than  are  obtained  by  the  graphic  method,  because 
a  certain  amount  of  arterial  distention  must  occur  before  the  pulse 
can  be  palpated.  If  a  sphygmograph  or  a  second  (radial)  cuff  is 
used  to  determine  the  return  of  the  pulse  instead  of  the  finger, 
somewhat  higher  readings  (10  to  15  mm.)  will  generally  be  obtained. 
The  end  of  the  maximum  oscillation  (diastolic  pressure)  can  be 
more  readily  determined  by  this  means  than  by  palpation,  especially 
in  the  case  of  the  novice. 

The  auscultatory  procedure  yields  results  which  are  closely  com- 
parable to  the  graphic  method,  provided  that  the  fourth  phase 
(muffling)  and  the  last  of  the  large  oscillations  be  chosen  as  the 
criteria  of  the  diastolic  pressure  (Lang  and  Manswetowa,  Bickel, 
Warfield,  Schrumpf  and  Zabel,  Engle  and  Allen).  If  the  fifth 
phase  is  chosen  Windle  found  that  the  results  corresponded  within 
5  mm.  In  the  average  case  it  will  not  make  more  than  this  degree 
of  difference  whether  we  choose  the  fourth  or  the  fifth  phase,  but 
in  cases  with  a  long  fourth  phase  the  discrepancies  may  amount 
to  10  to  12  mm.  With  a  little  training  the  fourth  phase  is  quite  as 
readily  recognized  as  the  fifth.  The  vast  majority  of  cases  show 
readings  5  mm.  higher  by  ausculatation  than  by  palpation. 

The  oscillatory  (visual)  method  tends  to  yield  higher  values  (5 
to  10  mm.)  than  that  of  palpation,  and  figures  practically  identical 
with  the  graphic  method  (Schrumpf  and  Zabel).  It  has  a  distinct 
field  of  utility  in  taking  the  pressures  of  infants  and  individuals 
with  very  small  pulse-pressures.  The  greatest  discrepancies  occur 
in  arteriosclerotic  cases. 


ANEROID  INSTRUMENTS  125 

The  graphic  method  is  more  time-consuming  and  troublesome 
than  the  other  methods,  but  in  the  hands  of  those  who  are  familiar 
with  its  technic  is  the  most  exact.  It  is  generally  accepted  as  a 
standard  of  clinical  accuracy.  The  actual  readings  are  considerably 
higher  than  the  endo-arterial  pressure.  The  margin  of  error  may 
be  as  high  as  25  per  cent. 

On  close  analysis  Zabel  found  that  when  well-marked  discrep- 
ancies existed  between  the  findings  of  different  methods,  the  phase 
of  "large  oscillations"  was  long,  whereas  in  the  class  in  which  the 
results  were  closely  in  accord,  this  phase  was  brief.  Careful  observa- 
tion, he  believes,  shows  that  the  phase  of  large  oscillations  really 
consists  of  two  distinct  parts.  In  the  beginning  the  first  large 
oscillations  exhibit  a  crescendo  quality  which  bespeaks  the  increas- 
ing pressure  in  the  edges  of  the  cuff.    Following  this  in  some  cases  a 


o  o  o 

-S  H 


0 


no 


Fig.  64. — The  diastolic  pressure  as  determined  by  different  methods.     (Bickel.) 

second  increase  in  the  oscillation  abruptly  occurs,  which  corresponds 
to  the  Ehret  phenomenon  and  to  the  beginning  of  Korotkow's 
third  phase.  According  to  this  conception  the  first  of  these  two 
diastolic  phenomena  occurs  when  the  central  portion  of  the  arterial 
lumen  is  collapsed;  the  second,  when  the  entire  lumen  is  obliterated. 
Thus  the 

First  critical  point  =  onset  of  large  oscillations  =  beginning 
of  fourth  auscultatory  phase  =  collapse  of  central  arterial  wall. 

Second  critical  point  =  onset  of  maximum  oscillations  =  Ehret's 
phenomenon  =  third  auscultatory  phase  =  complete  arterial 
occlusion. 

In  corroboration  of  this  hypothesis  are  the  facts  that  (1)  in 
brachial  arteriosclerosis  Ehret's  phenomenon  is  of  gradual,  not 
sudden,  onset;  (2)  lacks  in  its  brusque  quality,  and  (3)  is  some- 
times entirely  absent. 


126    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 


RELATIVE  ADVANTAGES  OF  THE  DIFFERENT  METHODS. 

In  order  to  obtain  the  greatest  accuracy  (as  in  experimental 
work)  and  for  the  purpose  of  having  permanent  demonstrable 
records  the  graphic  method  excels. 

For  routine  clinical  work  where  simplicity  and  celerity,  com- 
bined with  reasonable  accuracy,  are  the  chief  desiderata,  the  auscul- 
tatory method  is  to  be  preferred.  The  older  palpatory  method  offers 
more  change  for  error,  due  to  the  personal  equation,  and  with  it 
much  more  difficulty  is  experienced  in  determining  the  diastolic 
pressure.  Furthermore,  the  auscultatory  method  has  to  a  con- 
siderable extent  eliminated  the  question,  "Which  sphygmoman- 
ometer shall  I  buy?"  Because  with  the  last-name  method  any 
accurate  manometer,  if  supplied  with  a  suitable  cuff,  etc.,  will 
answer  the  purpose. 

The  sphygmographic  attachment  at  the  wrist,  aside  from  being 
troublesome  to  adjust,  results  in  venous  stasis,  which  elevates 
the  curve  and  diminishes  the  excursions.  The  oscillatory  devices 
have  the  disadvantage  that  the  eye  has  to  measure  two  different 
points  at  once.  They  are  useful,  however,  when  the  pulse  is  small, 
and  some  of  them  can  be  used  to  register  the  pulsation  in  the  smaller 
arteries.  So  far  as  clinical  accuracy  is  concerned,  it  is  not  of  great 
moment  which  method  is  employed.  The  results  will  generally 
not  vary  more  than  10  mm.  Hg.,  figures  well  within  the  range  of 
allowable  error.  These  clinical  methods  are  after  all  only  relative 
estimations,  and  if  the  same  instrument  is  used  on  all  cases,  and 
the  examiner  is  conversant  with  the  technic,  the  results  will  be 
sufficiently  accurate  for  comparison  and  for  practical  purposes 
generally. 

Sources  of  Error.^ — There  is  a  more  or  less  prevalent  impression 
that  marked  errors  in  the  clinical  determination  of  blood-pressure 
may  be  brought  about  through  the  varying  influence  of  the  soft 
tissues  surrounding  the  artery,  such  as  the  size  and  muscular 
development  of  the  arm. 

In  the  investigations  of  Miiller  and  Blauel,^  conducted  on  arms 
about  to  be  amputated  and  controlled  by  manometrical  pressure, 
readings  from  the  artery  directly  showed  that  the  broad  cuff  gave 
a  reading  about  10  mm.  higher  than  the  actual  pressure,  a  margin 
of  error  which  waxed  larger  as  the  width  of  the  cuff  was  decreased. 

'  Zur  Kritik  des  Riva-Roccischen  u.  gartnerschen  Sphygmomanometers,  Deutsch. 
Arch.  f.  kUn.  Med.,  1907,  xci,  517. 


RELATIVE  ADVANTAGES  OF  THE  DIFFERENT  METHODS   127 

But  both  Hensen^  and  Janeway^  have  reported  cases  with  very 
great  differences  between  the  soft  parts  of  the  two  arms  (atrophy 
flaccidity  against  hypertrophy)  which  yielded  identical  readings  on 
the  two  sides.  Certainly  if  an  error  exists  it  lies  well  within  the 
limits  of  daily  physiological  fluctuation,  provided  a  cuff  with  a 
width  of  12  cm.  is  employed. 

The  extent  of  the  role  played  by  hypertonicity  of  the  arterial  wall 
in  causing  erroneous  blood-pressure  readings  has  been  much  dis- 
cussed. It  has  been  claimed  that  some  of  the  excessively  high 
readings  occasionally  obtained  in  man  (350  mm.  or  over)  could 
not  represent  the  actual  endovascular  tension,  but  must  be  due 
to  resistance  of  the  arterial  wall. 

The  subject  has  been  reviewed  and  studied  in  a  series  of 
ingenious  experiments  by  Janeway  and  Park,^  who  found  that 
although  the  arterial  wall  does  offer  definite  resistance  to  com- 
pression, greater  in  large,  thick-walled  vessels,  yet  this  resistance 
in  a  normal  adult  brachial  is  equivalent  to  only  a  few  millimeters 
of  mercury.  In  children  it  is  an  entirely  negligible  factor,  and  in 
adults  with  a  normal  blood-pressure  the  error  thus  introduced  into 
clinical  blood-pressure  measurements  is  not  greater  than  10  mm. 
Hg.,  "a  figure  less  than  the  spontaneous  variations  in  pressure 
from  minute  to  minute." 

"Atheroma,  even  of  considerable  degree,  is  without  appreciable 
effect  on  the  compressibility.  Calcification  of  the  arterial  wall, 
when  segments  longer  than  6  cm.  are  examined,  increases  only 
moderately  its  resistance  to  compression.  The  overpressure 
dependent  on  this  factor  in  our  experiments  did  not  exceed  17  mm. 
Hg.  In  clinical  blood-pressure  determinations,  if  a  wide  arm-piece 
be  used,  and  the  return  of  the  first  fully  developed  pulse  wave  be 
taken  as  the  index,  as  recommended  by  von  Recklinghausen,  even 
advanced  arterial  thickening  and  calcification  probably  do  not 
introduce  an  error  of  any  importance.  The  only  factor  altering 
the  compressibility  of  an  artery  which  seems  capable  of  introducing 
an  error  of  real  importance  in  the  clinical  measurement  of  systolic 
blood-pressure  is  the  state  of  contraction  of  the  arterial  walls. 
It  is  impossible  from  our  experiments  on  surviving  ox  arteries  to 
set  definite  numerical  limits  for  this  in  man.    From  these  experi- 

»Beit.  z.  Physiol,  u.  Path.  d.  Blutdrucks,  Deutsch.  Arch.  f.  kliii.  Med.,  1900, 
Ixviii,  443. 

^  Influence  of  the  Soft  Tissues  of  the  Arm  on  Clinical  Blood-pressure  Determina- 
tions, Arch.  Int.  Med.,  1907. 

^  An  Experimental  Study  of  the  Resistance  to  Compression  of  the  Arterial  Wall, 
Arch.  Int.  Med.,  November,  1910. 


128    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

ments,  however,  combined  with  our  study  of  human  arteries  after 
amputation  and  postmortem,  we  feel  that  a  degree  of  hypertonic 
contraction  of  the  brachial  artery  sufficient  to  cause  an  error  of 
more  than  30  mm.  Hg.  seems  improbable,  and  of  more  than  60  mm. 
incredible,  during  life"  (Janew^ay). 

Practically  all  the  evidence  at  hand  supports  the  foregoing 
statements.  The  latest  corroboration  is  furnished  by  Macwilliam 
and  Keeson,^  who  found  that  relaxed  arteries  (Ringer's  solution, 
manipulation,  sodium  fluoride)  with  normal  or  thickened  walls 
yielded  only  trivial  degrees  of  resistance  to  compression.  Thickened 
arteries  from  old  animals,  especially  when  contracted  (barium 
chloride,  epinephrin)  below  the  body  temperature,  were  capable  of 
exerting  considerable  resistance.  In  the  smaller  arteries  constric- 
tion was  sometimes  sufficient  to  resist  a  passage  of  fluid  of  440 
mm.  Hg.  Arterial  contraction  in  such  arteries  could  be  greatly 
diminished  by  repeated  or  long-continued  compression  and  by 
massage  of  the  artery.  This  procedure,  they  suggest,  may  be  used 
to  determine  how  great  a  percentage  of  a  high  pressure  is  due  to 
vascular  resistance,  although  it  does  not  enable  one  to  determine 
whether  this  vascular  resistance  is  due  to  arterial  contraction  or 
to  other  causes. 

They  have  further  shown  that  soft  spots  in  the  course  of  an 
irregularly  sclerosed  artery  are  not  bridged  over  by  the  brachial 
cuff  but  that  the  latter  acts  effectively  even  in  very  limited  soft 
areas,  thus  preventing  the  resistance  offered  by  the  re?t  of  the 
artery  from  having  any  great  effect  upon  the  readings  of  the 
instrument. 

Much  stress  has  been  laid  by  some  investigators  upon  variability 
of  the  conduction  of  the  pulse  wave  due  to  alteration  in  the  arterial 
lumen  and  changes  in  the  resiliency  of  the  arterial  wall.  Thus 
Hill  believes  that  systolic  pressure  readings  are  affected  by  (a) 
the  actual  maximum  pressure  of  cardiac  systole;  (6)  the  conduction 
of  the  pressure  wave  to  the  periphery.  The  resistance  of  the  arterial 
wall  to  compression  affects  the  systolic  index  of  blood-pressure 
but  little,  but  the  relative  hardness  or  softness  of  the  vessel  affects 
the  conduction  of  the  systolic  wave  considerably,  especially  if 
it  is  large.  The  force  of  the  wave  is  damped  down  in  soft  arteries 
as  sound  waves  are  damped  by  velvet.^ 

1  The  Estimation  of  Systolic  Blood-pressure  in  Man,  with  Special  Reference  to 
the  Influence  of  the  Arterial  Wall,  Heart,  1913,  iv,  279. 

2  Hill,  L.:  Measurement  of  Systolic  Blood-pressure  in  Man,  Heart,  1910,  i,  73. 
Hill  and  Rowlands:    Heart,  1912,  iii,  219. 


PRECAUTIONS  TO  BE  OBSERVED  IN  TAKING  READINGS    129 

Most  of  the  experimental  evidence,  however,  indicates  that 
constrictions  of  the  artery  sufficient  to  cause  any  considerable 
diminution  of  conduction  can  hardly  occur  between  such  large 
vessels  as  the  aorta  and  brachial  artery;  and  further,  that  increased 
arterial  rigidity  is  equally  insufficient  to  cause  an  important  source 
of  error.  The  difference  in  pressure  obtained  in  arm  and  leg,  or  two 
arms  or  two  legs,  is  the  result  of  pressure  differences  in  the  arteries 
in  question,  and  not  due  to  abnormal  conduction  of  the  aortic 
pressure. 

The  elasticity  of  the  aorta  and  its  branches  is  important  in 
causing  a  lower  systolic  and  a  higher  diastolic  pressure  in  the 
systemic  arteries  than  would  a  rigid  tube,  but  in  blood-pressure 
estimations  by  the  obliteration  method,  the  resiliency  of  the  inter- 
vening arterial  tube  appears  to  be  negligible,^ 

PRECAUTIONS  TO  BE  OBSERVED  IN  TAKING  READINGS. 

Blood-pressure  readings  should,  for  purposes  of  comparison, 
always  be  taken  in  the  same  (preferably  the  horizontal)  posture. 
At  all  events  the  position  should  be  such  that  the  reading  is  made 
at  a  point  about  on  a  level  with  the  heart,  thus  eliminating  the 
error  due  to  the  weight  of  the  blood  column.  When  possible, 
observations  should  be  made  about  the  same  time  of  day  and  in 
the  same  relation  to  meals.  They  should  not  be  taken  during 
excitement,  after  exercise,  or  shortly  after  the  patient  has  partaken 
of  hot  food  or  drink,  tea,  coffee  or  alcohol,  and  not  when  the  extremi- 
ties are  overheated  or  chilled.  All  muscular  activity  on  the  part 
of  the  patient  must  be  prevented  and  complete  relaxation,  both 
general  and  local,  obtained.  Observations  made  under  conditions 
of  spasm — subsultus,  tetanus,  etc. — are  absolutely  unreliable. 
Edema  of  the  tissues  is  also  a  fertile  source  of  error,  and  readings 
obtained  from  anasarcous  patients  are  of  no  value.  Fear,  excite- 
ment or  psychic  effort  have  a  marked  effect  on  the  blood-pressure. 
In  taking  one's  own  pressure,  higher  results  are  often  found  than 
those  obtained  by  another  observer  immediately  before  or  after- 
ward, simply  as  the  result  of  psychic  concentration.  Schrumpf 
relates  an  instance  in  which  the  anticipation  of  an  austere  prognosis 
raised  the  pressure  of  a  patient  33  per  cent.,  to  fall  again  promptly 
when  reassurance  was  forthcoming,  and  only  to  rise  once  more 
when  complaining  of  his  insomnia  and  worries.    Gibson  found  that 

'  Macwilliam,  Kesson,  and  Meloin:     The  Conduction  of  the  Pulse- wave  and  its 
Relation  to  the  Estimation  of  Systolic  Blood-pressure,  Heart,  1913,  iv,  393. 
9 


130    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

his  own  pressure  was  increased  35^0  mm.  after  delivering  a  lecture. 
Due  allowance  for  variability  of  the  systolic  pressure  must  always 
be  made  in  neurotic  patients. 

Von  Recklinghausen  observed  in  his  own  case  a  rise  of  14  cm. 
H2O  caused  by  the  entrance  into  his  presence  of  a  person  whom  he 
intended  to  berate  (see  Physiological  Variations).  Putermann^ 
found  that  the  anticipation  of  an  examination  almost  without 
exception  raised  both  blood-pressure  and  pulse  rate  in  school- 
children. In  extreme  cases  psychic  states  may  cause  a  rise  of  90 
mm.  Hg.,  generally  in  association  with  marked  pleasure,  anger,  or 
fright.  The  diastolic  pressure  in  these  cases  is  practically  unaffected.^ 
The  interposition  of  a  thin  undergarment  between  the  cuff  and 
the  arm  is  unobjectionable,  in  fact,  may  be  positively  beneficial. 
In  cold  weather  a  chilly  cuff  applied  to  the  arm,  both  by  the  dis- 
pleasure it  causes  the  patient,  and  by  the  stimulating  effect  it  has 
upon  the  vasomotor  nerves,  may  yield  erroneous  readings.  In 
very  high-strung  individuals  it  is  best  to  warm  the  cuff  before 
applying  it. 

It  sometimes  happens  that  the  initial  systolic  blood-pressure 
reading  on  a  given  subject  yields  distinctly  higher  figures  than  can 
be  obtained  in  subsequent  attempts.  Gallavardin  and  Haour' 
found,  in  the  study  of  100  cases,  that  this  initial  high  pressure, 
which  may  amount  to  35  mm.  in  women  and  25  mm.  in  men,  may 
last  fifteen  minutes,  although  in  50  per  cent,  of  these  cases  the 
normal  point  was  reached  at  the  end  of  five  minutes.  Only  the 
systolic  pressure  was  affected,  the  diastolic  level  remaining  constant. 
These  figures  are  certainly  high. 

Such  an  increased  pressure  may  be  due  to:  (1)  Psychic  influences 
—excitement  or  fear,  chiefly  noted  in  high-strung  individuals. 
(2)  Pain — arising  from  the  forcible  inflation  of  the  cuff  on  sensitive 
arms  or  in  cases  of  marked  hypertension.  (3)  Local  stimulation 
of  the  vasomotor  nerves  from  pressure.  (4)  Prolonged  application 
of  the  cuff.  This  tends  to  relax  the  artery,  and  by  reflexly  dimin- 
ishing the  force  of  systole,  possibly  lessens  the  conduction  of  the 
plulse  wave.  It  also  produces  marked  increase  in  the  venous  pressure 
and  congestion  of  the  tissues  below  the  cuff". 

Attention  has  been  called  to  the  fact  that  in  estimating  the 

1  Ueber  d.  Beeinflussung  d.  Zirkulationssystem  durch  d.  Schulexaniina,  Wien. 
med.  Wchrischr.,  1904,  liv,  265. 

2  Schrumpf ,  P. :  Die  psychogene  Labilitiit  des  Blutdrucks  u.  ihre  Bedeutuiig  in 
d.  Praxis,  Deutsch.  med.  Wchnschr.,  1910,  xxxvi,  238.5. 

*  Braise  systolique  de  la  tension  arterielle  au  moment  de  la  mensuration,  Arch,  de 
mal.  du  ccDur,  etc.,  1912,  v,  81. 


THE  PERSONAL  EQUATION  OF  THE  EXAMINER        131 

diastolic  pressure  by  increasing  the  manometer  pressure,  different 
results  are  sometimes  obtained  than  when  the  diastolic  index  is 
taken  during  a  falling  manometric  pressure,  especially  if  the  press- 
ures are  gauged  on  both  arms  simultaneously,  A  comparison  of 
the  diastolic  values  with  a  rising  pressure  may  thus  indicate  an 
abnormal  tendency  toward  blood-prassure  variation  in  a  given 
individual.^ 


THE  PERSONAL  EQUATION  OF  THE  EXAMINER. 

Schultze^  found  that  ordinarily  with  a  trained  observer  a  series 
of  ten  successive  measurements  will  yield  a  fair  average  of  accuracy. 
Much  closer  correspondence  in  successive  readings  is  obtained  if 
the  manometer  is  read  and  the  pulse  palpated  by  the  same  person, 
than  if  these  duties  are  relegated  to  two  individuals.  This  results 
from  the  strained  mental  attitude  of  the  palpator  who  is  almost 
certain  to  become  "the  dupe  of  expectant  attention,"  knowing 
that  his  sense  of  touch  is  being  "controlled"  and  fearing  lest,  after 
all,  he  fail  to  feel  the  first  pulse  wave.  His  sense  of  perception  being 
therefore  raised  to  its  maximum,  it  often  happens  that  he  becomes 
subjectively  conscious  in  his  finger-tips  of  his  own  pulse,  especially 
if,  as  is  necessary  for  accuracy,  the  manometric  pressure  is  allowed 
to  fall  but  slowly,  and  the  procedure  is  therefore  prolonged.  Sub- 
jective appreciation  of  the  pulse  is  more  marked  in  the  second 
finger,  and  in  certain  individuals.  It  is  generally  perceived  from 
ten  to  thirty  seconds  after  the  finger-tips  of  a  dependent  hand  have 
been  lightly  placed  upon  a  solid  object  (e.  g.,  table).  This  factor 
is  in  our  experience  only  rarely  a  cause  of  confusion. 

The  frequency  with  which  the  subjective  pulse  appears  in  "con- 
trolled" observers  indicates  how  variable  is  the  acuteness  of  our 
tactile  perception.  If  the  pressure  is  read  and  the  pulse  is  palpated 
by  the  same  individual  the  discrepancies  of  successive  readings 
will  be  far  smaller,  owing  to  the  subjective  suggestible  element 
(expectant  attention).  The  first  reading  having  yielded  a  definite 
result,  we  consciously  or  unconsciously  "expect"  the  pulse  to 
reappear  at  about  the  same  level.  This  is  illustrated  by  Schultze 
in  Fig.  G5,  which  shows  how  much  more  closely  the  results  of  ten 

*  Macwilliam,  J.  A.,  and  Melvin,  G.  S. :  The  Significance  of  Blood-pressure 
Readings  in  Man,  British  Med.  Jour.,  1914,  p.  777. 

'  Ueber  d.  psychologischen  Fehlerquellen  bei  d.  palpatorischen  Bludruckmes- 
sung  nach  Riva-Rocci  u.  v.  Recklinghausen:  Arch.  f.  d.  ges  Physiol.,  Bonn,  1908, 
cxxiv,  392. 


132    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

consecutive  readings  corresponded  when  the  suggestible  element 
is  not  eliminated. 

In  the  first  two  estimations,  I  and  II  (10  each),  the  examiner 
observed  the  manometer  while  feeling  for  the  pulse  wave;  in  the 
last  two,  III  and  IV,  the  manometer  was  not  read  until  after  the 
pulse  wave  was  perceived. ^  When  the  suggestible  element  was 
eliminated,  successive  readings  tallied  less  closely. 


Fig.  65. — In  the  first  two  estimations,  I  and  II,  the  manometer  was  observed  while 
feeling  the  pulse  wave.  In  the  last  two,  ///  and  IV,  the  manometer  was  not  read 
until  after  the  pulse  wave  had  been  perceived. 


Another  possible  source  of  error  lies  in  the  fact  that  the  threshold 
of  perception  for  the  appearing  and  disappearing  pulse  are  not  the 
same.  In  the  former  we  judge  of  a  subsensible  stimulus  which 
is  being  raised  to,  in  the  latter  of  a  sensible  stimulus  which  is  being 
lowered  beyond,  the  point  of  perception.  The  point  of  disappear- 
ance is  definitely  more  difficult  to  determine.  Finally,  the  mercury 
in  the  manometer  rarely  if  ever  rises  or  falls  so  gradually  that  the 
examiner  has  time  to  decide  for  each  individual  millimeter  of 
pressure  whether  or  not  a  pulsation  is  present.     Therefore  our 

'Schultze:  Ueber  d.  psychologischen  Fehlerquellen  dei  d.  palpatorischen  Blu- 
druckmessung  nach  Riva-Rocci  u.  v.  Recklinghausen:  Arch.  f.  d.  ges  Physiol., 
Bonn,  1908,  cxxiv,  392. 


ACCURACY  AND  SIGNIFICANCE  OF  BLOOD-PRESSURE     133 

measurements  are  for  subjective  reasons  generally  exact  only  within 
3  or  5  mm.  Hg. 

In  order  to  minimize  all  these  sources  of  error  the  following  pro- 
cedures should  be  adopted:  (1)  Discard  the  result  of  the  first 
reading,  using  it  simply  to  demonstrate  the  harmless  and  painless 
character  of  the  procedure;  and  when  possible  make  subsequent 
readings  after  some  little  time  has  elapsed.  (2)  Avoid  making 
blood-pressure  estimations  when  the  subject  is  excited,  anxious  or 
worried,  as  a  result  of  the  examination,  etc.  (3)  Make  several 
consecutive  readings  and  if  they  correspond  more  or  less  closely, 
take  the  arithmetic  mean.  (4)  Make  the  observations  as  quickly 
as  is  consistent  with  accuracy;  do  not  look  at  the  manometer  until 
the  pulse  is  felt — at  this  point  the  air  escapement  should  be  tightly 
closed  until  the  reading  is  made.  (5)  Allow  the  pressure  to  fall  to 
zero  between  observations,  and  permit  sufficient  time  to  elapse 
between  readings  for  the  venous  pressure  (stasis)  to  fall  to  the 
normal  level.  Never  make  a  reading  with  a  broken  mercurial 
column,  and  be  sure  that  the  mercury  corresponds  with  the  zero 
on  the  scale  before  inflation.  Needless  to  say,  most  of  these  sources 
of  error  are  eliminated  by  using  the  auscultatory  method  which 
has  therefore  come  into  merited  favor. 

In  certain  forms  of  cardiac  arrhythmia,  especially  auricular  fibrilla- 
tion and  extrasystole,  it  becomes  very  difficult  to  gauge  the  blood- 
pressure,  as  the  pulse  is  never  equal  in  volume  or  in  tension  for 
many  consecutive  beats.  A  rough  estimate  of  the  actual  pressure 
may  be  obtained  by  measuring  first  the  strongest  and  then  the 
weakest  pulsations  and  thus  establishing  an  average.  (See  Auricular 
Fibrillation.) 

Possible  Accidents. — In  certain  dyscrasic  states — purpura,  hemo- 
philia, etc. — too  prolonged  application  of  a  highly  inflated  cuff 
may  cause  capillary  hemorrhage.    This  is  very  rarely  the  case. 

Mohr  has  reported  thrombosis  following  repeated  bfood-pressure 
observations  in  a  patient  suffering  from  tuberculous  pneumonia. 
This  is,  we  believe,  the  only  case  of  the  kind  on  record.  Hill  has 
reported  edema  in  a  paralytic  arm  following  the  application  of  the 
cuff  in  a  case  with  a  blood-pressure  of  220  mm. 

THE  VALUE,  ACCURACY  AND  SIGNIFICANCE  OF  BLOOD- 
PRESSURE  ESTIMATIONS. 

Blood-pressure  readings  furnish  us  with  important  and  valuable 
data,  but  they  must  be  interpreted  in  relation  to  other  physical 


134    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 


signs.  Such  observations  alone  do  not  furnish  us  with  a  basis  for 
treatment  any  more  than  they,  unaided,  permit  us  to  make  a  diag- 
nosis. In  this  respect  a  sphygmomanometer  is  Hke  a  thermometer 
— its  readings  must  be  construed  in  the  light  of  other  findings. 
We  have  seen  cases  exhibiting  a  practically  normal  systolic  and 
diastolic  pressure  associated  with  dyspnea,  cyanosis,  and  edema, 
showing  that  the  blood  flow  was  not  normal. 

Observations  of  the  systolic  pressure  alone  are  of  relatively  little 
value.  They  indicate,  it  is  true,  the  strain  to  which  the  arteries 
are  subjected,  but  the  diastolic  pressure,  the  variations  of  which 
correspond  more  or  less  closely  to  those  of  the  mean  pressure,  is 
the  real  indication  of  the  work  the  heart  has  to  do.  Systolic  pressure 
may  suddenly  vary  greatly  from  many  diverse  causes — fright, 
excitement,  etc. — but  the  diastolic  pressure  is  a  much  less  easily 
disturbed  factor,  and  may  hence  be  a  valuable  criterion  in  deciding 
w^hether  organic,  vascular  or  cardiac  changes  are  present.  Since 
the  diastolic  pressure  can  now  be  readily,  quickly  and  accurately 
determined  by  observing  the  appearance  of  the  fourth  auscultatory 
phase,  there  can  no  longer  he  any  excuse  for  neglecting  this  far  more 
important  of  the  two  phases  of  arterial  tension.  We  have  already 
learned  in  most  conditions  to  attribute  more  importance  to  the 
diastolic  than  to  systolic- readings. 

Pulse-pressure. — The  difference  between  the  systolic  and  the 
diastolic  pressure  roughly  indicates  the  volume  of  the  pulse.  From 
a  study  of  pulse-pressure  certain  deductions  can  often  be  drawn, 
but  it  must  be  remembered  that  these  are  not  absolute  nor  always 
trustworthy  criteria.^ 


Increased  peripheral  resistance 
Decreased  peripheral  resistance 
Increased  heart  rate 
Decreased  heart  rate 
Increased  systolic  discharge 
Decreased  systolic  discharge 


Systolic 
pressure. 

+ 
.  + 

.'       +  + 


Diastolic 
pressure. 

+  + 

+  + 

+ 


Pulse- 
pressure. 


+ 


The  diastolic  pressure  is  normally  about  three-fourths  of  the 
systolic  pressure  and  the  pulse-pressure,  one-quarter  of  the  systolic 
pressure.  A  puke-pressure  persistently  as  low  as  20  or  as  high  as 
60  mm.  is  definitely  pathological. 

The  normal  pulse-pressure  in  adults  ranges  between  30  and 
50  mm.  A  pulse-pressure  of  45  approximates  the  average  normal 
for  individuals  below  the  middle  period  of  life. 

'  Wiggers,  C.  J.:  Modern  Aspects  of  the  Circulation  in  Health  and  Disease, 
PhUadelphia,  1915,  p.  68. 


ACCURACY  AND  SIGNIFICANCE  OF  BLOOD-PRESSUliE     135 

As  long  as  the  aorta  is  elastic  and  the  arteries  resilient  this  amount 
of  increased  pressure  is  sufficient  to  keep  up  an  adequate  peripheral 
blood  flow.  When,  however,  the  vessels  become  sclerotic,  a  larger 
systolic  output  is  required  to  maintain  peripheral  nutrition  and  hence 
the  pulse-pressure  must  be  increased.  This  increase  which  is  met 
with  after  the  middle  period  of  life  is  therefore  a  compensatory 
phenomenon,  which  within  certain  limits  may  be  regarded  as  an 
index  of  the  degree  of  sclerosis  present. 

The  normal  pulse-pressure  increment  is  greater  after  sixty  years 
than  between  forty  and  sixty. 

As  a  method  of  calculating  what  the  normal  for  a  given  individual 
should  be,  Oliver  suggested  the  following  rule:  Add  to  the  average 
pulse-pressure  before  forty  (i.  e.,  45  mm.)  1  mm.  for  every  two  years 
from  forty  and  sixty  years  and  1  mm.  per  year  for  each  year  after 
sixty.  Thus  a  man  of  seventy  years  would  be  entitled  to  a  pulse- 
pressure  of  65  mm.  (i.  e.,  45  +  20). 

The  increased  pressure  of  advancing  years  results  from  cardiac 
hypertrophy  and  when  merely  normal  aging,  is  due  mainly  to  an 
increase  of  the  systolic  pressure.  If  an  increased  pulse-pressure 
once  established,  subsequently  diminishes,  as  the  result  of  a  rising 
diastolic  pressure,  we  are  warranted  in  assuming  that  a  pathological 
factor  has  been  added.  In  other  words,  we  are  no  longer  dealing 
with  a  normal  senile  change,  but  with  an  abnormal  vascular  con- 
dition; generally  Bright's  disease. 

A  large  pulse-pressure  if  constantly  maintained  will  be  found 
associated  by  left  ventricular  enlargement  and  myocardial  hyper- 
trophy. In  addition,  dilatation  of  the  aortic  arch  is  also  generally 
encountered.  Warfield^  states  that  when  the  pulse-pressure  exceeds 
70  mm.,  the  large  distributing  arteries  will  be  found  enlarged,  and 
upon  microscopic  examination  will  show  fibrosis  of  the  medial  coat. 

Large  pulse-pressure  is  encountered:  in  aortic  insufficiency, 
chronic  nephritis,  arteriosclerosis  and  in  exophthalmic  goitre,  and 
in  many  vasomotor  crises.  Small  pulse-pressures  are  met  with  in 
asthenic  conditions,  when  the  muscle  is  no  longer  able  to  supi)ly 
the  required  systolic  output.  This  is  often  seen  in  failing  compen- 
sation, in  mitral  and  aortic  obstruction,  in  shock,  collapse,  anemia, 
hemorrhage  and  cachexia.  Pulse-pressures  of  less  than  30  mm.  are 
not  often  encountered  over  prolonged  periods  because  the  blood 
supply  is  apparently  insufficient  to  maintain  the  functionation  of  the 
viscera. 

'The  Significance  of  High  Pulae-pressure,  Jour.  Am.  Med.  Assn.,  1917,  Ixviii,  824. 


136    I r^'^TRU MENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

As  a  rule  the  rate  of  blood  flow  through  the  arterioles  tends  to 
vary  (within  certain  limits)  directly  with  the  pulse-pressure.^  The 
functional  efficiency  of  the  viscera,  as  shown  by  perfusion  experi- 
ments, also  stands  in  a  direct  relation  with  the  size  of  the  pulse- 
pressure.  In  order  that  secretion  and  excretion  shall  occur  there 
must  exist  not  only  a  given  pressure  but  an  intermittent  pressure. 
The  flow  of  urine  as  well  as  its  urea  and  chloride  content,  varies 
directly  with  the  pulse-pressure^  and  the  diuresis  of  digitalis  and 
strophanthus  is  due  to  the  increased  pulse-pressure  which  these 
drugs  produce.^  The  importance  of  the  pulse,  and  the  diastolic 
pressures  far  exceeds  in  value  the  estimation  of  the  systolic  pressure 
alone. 

A  high  systolic,  with  a  normal  diastolic,  pressure  may  result  from 
emotional  disturbances  and  as  a  result  of  physical  exertion. 

A  low  systolic,  with  a  high  diastolic,  pressure  often  indicates  myo- 
cardial weakness  in  association  with  severe  pressor  factors  such  as 
nephritis  or  vascular  spasm. 

A  low  systolic  and  diastolic  pressure  occurring  in  a  person  who 
is  up  and  about  (essential  hypotension),  while  it  does  not  necessarily 
imply  a  poor  circulation,  is  definitely  associated  with  diminished 
reserve  force — "staying  power." 

A  high  systolic,  with  a  low  diastolic,  pressure  is  most  characteris- 
tically seen  in  aortic  insufficiency;  it  may,  however,  result  from 
peripheral  vascular  dilatation  associated  with  forcible  heart  action. 

THE  EXTREMES  OF  PRESSURE  COMPATIBLE  WITH  LIFE. 

Hypertension. — Systolic  blood-pressures  above  235  mm.  are 
unusual  and  above  250  mm.  are  rare.  Hirst  has  reported  a  recovery 
in  puerperal  eclampsia  with  a  pressure  of  420  mm.  Hg.  Needless 
to  say,  such  a  pressure  could  not  long  be  maintained  without  some- 
thing giving  out.  Many  patients  live  for  years  with  pressures 
ranging  about  200  systolic  and  120  diastolic,  and  occasionally  such 
pressures  are  compatible  with  hard  manual  labor,^  but  a  sudden 
termination  in  these  cases  is  always  a  possibility.  Strauss's  patient 
lived  for  five  years  with  a  systolic  pressure  between  260  and  270  mm. 
Cook  and  Briggs  reported  400  mm.  in  a  case  of  cerebral  hemorrhage. 

»  Macwilliam,  J.  A.,  and  Melvin,  G.  S.:  British  Med.  Jour.,  1914,  i,  693. 

2  Erlanger  and  Hooker:  Johns  Hopkins  Hosp.  Rep.,  1904,  xii,  346.  Hooker: 
Arch.  Int.  Med.,  1910,  v,  491. 

»  Gesell:     Am.  Jour.  Physiol.,  1913,  xxxii,  70. 

*McCurdy,  S.  M.:  Physical  Examination  and  Regeneration  of  Employees,  Jour. 
Am.  Med.  Assn.,  1915,  Ixv,  2050. 


CHOICE  OF  AN  INSTRUMENT  137 

Hypotension. — ^A  systolic  pressure  of  105  is  common  among  many 
essential  hypotension  cases  which  are  up  and  about.  Not  many 
are  able  to  be  so,  however,  if  the  systolic  pressure  falls  below  100 
or  the  diastolic  below  50.  RoUeston  has  reported  a  remarkable 
case  of  a  man  with  a  lingual  carcinoma,  who  lived  for  several  weeks 
with  systolic  and  diastolic  pressures  of  70  and  35  respectively. 
Agonal  systolic  pressures  of  40  mm.  have  been  reported  and  60 
mm.  probably  represents  the  lowest  figure  at  which  the  coronary 
and  medullary  circulation  can  be  kept  up,  even  for  a  short  time. 
Some  of  the  earlier  figures,  such  as  those  of  John,  of  35  to  40  in 
a  case  of  advanced  tuberculosis,  are  open  to  question  on  account 
of  faulty  instrumentation.  Janeway  has  seen  systolic  pressures  of 
40  mm.  as  transient  phenomena  during  surgical  operations. 

All  clinical  blood-pressure  estimations  must  be  accepted  only  as 
approximately  correct.  In  addition  to  the  fact  that  the  determi- 
nation of  the  diastolic  pressure  presents  certain  difficulties  we  are 
confronted  with  the  fact  that,  even  if  this  could  be  accurately 
measured,  we  would  still  be  only  measuring  the  blood-pressure  of 
the  brachial  artery.  Living  vessels  possess  a  distinct  tonus — the 
ability  to  contract  and  to  dilate — the  amount  of  which  in  a  given 
case  we  are  thus  far  unable  to  determine.  In  addition  to  this 
we  must  bear  in  mind  that  the  blood-pressure  mechanism  is  an 
extremely  labile  one  which  is  subject  to  frequent  fluctuations,  due 
to  many  different  causes. 

On  the  other  hand,  thousands  of  blood-pressure  measurements 
on  different  individuals  have  shown  that  pressure  relations  are 
fairly  constant  under  similar  circumstances;  that  there  are  definite 
and  distinct  bounds  beyond  which  normal  variations  do  not  extend, 
and  again  that  there  are  certain  abnormal  values  which,  if  con- 
stantly found  in  a  given  individual,  point  very  definitely  to  well- 
established  pathological  conditions. 

THE  CHOICE  OF  AN  INSTRUMENT. 

For  general  office  work  some  instrument  of  the  Riva-Rocci  type 
is  unquestionably  to  be  preferred.  Of  this  type  of  instrument  a 
great  many  different  models  have  been  placed  on  the  market. 
Although  varying  in  detail  of  construction  they  are  all  based  on 
the  same  principle.  Good  results  may  be  obtained  with  most  of 
them.  On  the  whole,  the  last  model  of  Nicholson's  sphygmo- 
manometer is  the  most  satisfactory  instrument  to  be  obtained, 
being  compact,  readily  portable  and  yet  possessing  the  advantages 


138    INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

of  the  mercury  monometer.  The  "Baumanometer,"  although 
more  bulky  and  less  readily  portable,  is  supplied  with  a  very  large, 
clear  scale  which  is  individually  standardized. 

In  the  personal  choice  of  an  instrument  we  should  be  governed 
by  a  number  of  factors,  i.  e.:  (I)  Accurate  standardization.  (2) 
General  workmanship.  The  instrument  should  be  made  of  flint 
glass,  as  the  lead  in  American  glass  reacts  with  the  mercury.  In 
the  same  way  the  mercury  will  form  an  alloy  if  allowed  to  come  in 
contact  with  any  metals  save  steel  and  platinum,  producing  tur- 
bidity and  increasing  friction.  It  is  also  affected  by  rubber,  owing 
to  the  sulphur  which  this  substance  contains.  All  joints  must  of 
course  be  tight.  It  is  essential  for  accuracy  that  the  cuff  have  a 
width  of  12  cm.  and  that  the  canvas  or  leather  backing  be  suffi- 
ciently rigid  to  maintain  the  width  of  the  aforesaid  rubber  portion. 
(3)  Compactness  and  portability — including  the  ease  and  celerity 
with  which  the  instrument  can  be  set  up  for  use,  the  devices 
employed  to  prevent  the  spilling  of  the  mercury  when  in  transit, 
and  the  bulk  of  the  apparatus  when  taken  down.  (4)  The  ampli- 
tude of  the  pulsation  transmitted  to  the  mercurial  column.  If  the 
auscultatory  method  of  blood-pressure  reading  be  employed,  the 
amount  of  visual  oscillation  obtainable  loses  its  importance,  and 
satisfactory  results  may  be  obtained  with  any  accurate  manometer 
if  fitted  with  a  proper  cuff. 

Compressed-air  manometers  are  small  and  accurate  (since  the 
stopcock  when  open  equalizes  barometric  and  temperature  varia- 
tions). The  adjustment  of  the  drop  used  as  an  indicator  is  some- 
times troublesome.  Aneroid  instruments  for  bedside  use,  owing 
to  their  small  size  and  ready  transportability,  have  much  to  com- 
mend them.  When  well  made  they  may  not  require  adjustment 
for  considerable  intervals,  although  comparisons  with  a  mercury 
manometer  must  from  time  to  time  be  made. 

Spring  manometers  require  frequent  standardization,  without 
which  procedure  inaccuracies  may  result.  The  von  Recklinghausen 
apparatus  is  somewhat  bulky  and  is  based  on  cubic  centimeter  H2O, 
which  standard  has  not  been  widely  adopted. 

The  kind  of  pump  selected  is  of  minor  importance.  The  rubber 
bulb  is  light  but  less  durable  than  the  heavier  metal  variety.  The 
von  Recklinghausen  bicycle-pump  type  is  both  heavy  and  bulky, 
but  one  or  two  strokes  suffice  for  inflation.  Compressed-air  tanks, 
such  as  are  currently  used  in  rhinological  work,  may  be  used  when 
rapid  inflation  of  the  cuff  is  desired.  Errors  due  to  stasis  may  thus 
be  minimized. 


CLASSIFICATION  OF  BLOOD-PRESSURE  INSTRUMENTS     139 

CLASSIFICATION  OF  BLOOD-PRESSURE  INSTRUMENTS. 

I.  Mercury  manometers : 

1.  Reservoir:    Riva-Rocci,    Cook    Stanton,    Nicholson, 

Hill,  Kercher,  Hollman,  Gartner,  Westenrijk. 

2.  U-shaped:  Bamn,  Janeway,  Faught,  Martin,  Linnell, 

Fellner,  Hamilton,  Schneider,  Beachler,  Brown, 
n.  Compressed-air  manometers :    Oliver,  Bendick,  Herz. 
ni.  Aneroid  manometers:    Sanborn,  Rogers,   Brunton,  Tycos, 

Faught,  Pachon,  Jacquet,  McKesson,  Bristol,  Fag. 
IV.  Spring  manometers :    von  Recklinghausen. 
V.  Instruments   for  graphic  registration:    Erlanger,    Gibson, 
Bingel,  Singer,  Uskoff,  Silbermann,  Brugsch,  Stursberg, 
IVIuenzer,   Strauss-Fleischer,   Bussenius,   Wybauw. 
VI.  Instruments  consisting  of  or  which  may  be  fitted  with  special 
oscillating  indices,  such  as  the  Fedde  or  Pal  oscillom- 
eters, Bing,  Nicholson,  Vaquez,  Faught,  Widmer. 


CHAPTER  IV. 
VENOUS  BLOOD-PRESSURE. 

By  J.  HAROLD   AUSTIN,  M.D. 

Various  methods  of  determining  venous  blood-pressure  in  man 
have  been  devised.    They  may  be  grouped  into  five  types: 

I.  Gartner's  Phenomenon. — Gartner/  in  1902,  contended  that  if 
the  left  arm  be  slowly  raised,  the  veins  at  the  elbow  which  become 
distended  when  the  arm  is  dependent  will  suddenly  collapse  upon 
reaching  a  certain  level.  He  assumed  that  the  elevation  of  this  point 
above  the  level  of  the  right  auricle  is  a  measure  in  centimeters  of 
blood  of  the  pressure  at  the  right  auricle.  It  is  to  be  remembered 
that  10  cm.  of  blood  equals  10.6  cm.  of  water.  As  the  level  of  the 
heart  Gartner  took  the  junction  of  the  upper  border  of  the  left  fifth 
costal  cartilage  w'ith  the  sternum.  Oliver^  used  the  same  method 
but  observed  the  veins  on  the  dorsum  of  the  hand.  Prym,^  however, 
showed  that  Gartner's  phenomenon  occurs  at  different  levels  when 
the  arm  is  raised  at  different  rates,  and  that,  moreover,  the  veins 
have  a  tonus  of  their  own  which  may  be  stimulated  by  cold  or 
by  stroking,  and  this  tends  to  accelerate  their  collapse.  Meinertz^ 
has  noted  that  exercise  of  one  arm  frequently  raises  the  level  at 
which  the  veins  collapse  in  that  arm  without  affecting  the  level 
in  the  other  arm.  The  state  of  the  circulation  and  vascular  tonus 
locally,  as  well  as  the  pressure  in  the  right  auricle,  therefore  influence 
Gartner's  phenomenon. 

n.  Spring  Manometers. — In  1898  Oliver^  attempted  to  measure 
venous  pressure  by  means  of  a  spring-pressure  manometer.  A 
button  attached  to  the  spring  of  the  manometer  was  pressed  against 
one  of  the  larger  veins  of  the  arm  with  sufficient  force  to  obstruct 
the' flow.  The  vein  for  an  inch  or  so  proximal  to  this  point  was 
then  stripped  by  the  finger.  The  pressure  against  the  vein  by  the 
manometer  was  then  gradually  reduced  and  at  the  moment  the 

'  Miinchen.  med.  Wchnschr.,  1904,  Ixxiv,  2038. 
2  Quart.  Jour.  Med.,  Oxford,  1907-08,  i,  69. 
'  Miinchen.  med.  Wchnschr.,  1904,  li,  60. 
*  Ztschr.  f.  cxper.  Pathol,  u.  Therap.,  1908. 
'  Jour.  Physiol.,  1898,  xxii,  li;  1898,  xxiii,  v. 


PRESSURE  CHAMBERS  OVER  THE  VEIN 


141 


emptied  section  of  vein  began  to  fill,  the  pressure  recorded  by  the 
manometer  was  noted.  This  was  believed  to  equal  the  venous 
pressure  at  that  point.  Subsequently  both  Frey^  and  SewalP 
independently  devised  similar  spring  manometers. 


Fig.  66. — Hooker's  venous  pressure  apparatus.  A  small  glass  chamber  (B)  measur- 
ing 1  by  2  cm.  is  held  temporarily  by  a  rubber  band  over  a  suitable  vein  on  the  back 
of  the  hand,  as  shown  at  A.  A  rim  of  collodion  is  applied  and  in  drying  it  seals 
the  chamber  to  the  skin.  The  rubber  band  is  then  removed  and  the  chamber  con- 
nected by  a  rubber  tube  to  the  water  manometer  (M).  By  pressing  on  the  man- 
ometer bulb  (C)  the  air-pressure  in  the  chamber' is  raised  and  a  reading  is  made  "at 
the  point  where  slight  oscillations  of  pressure  cause  the  vein  shadow  to  come  and  go 
promptly  just  before  the  vessel  is  completely  collapsed."  This  pressure  is  recorded 
directly  by  the  water  manometer.  The  hand  is  held  at  the  level  of  the  midpoint  of 
the  anteroposterior  diameter  of  the  body  at  the  costal  angle. 

in.  Pressure  Chambers  Over  the  Vein  (Fig.  66). — In  1904  von 
Basch'  attempted  to  measure  venous  pressure  by  placing  a  small 
glass  cylinder  over  the  vein,  and  raising  the  air-pressure  in  the 


1  Deutsch.  Arch.  f.  klin.  Med.,  1902,  Ixxiii,  511. 

«Jour.  Am.  Med.  Assn.,  1906,  xlvii,  1279;  Tr.  Assn.  Am.  Phys.,  Philadelphia, 
1906,  xxi,  20. 

'  Wien.  klin.  Rundschau,  1900,  pp.  549  and  572. 


142  VENOUS  BLOOD-PRESSURE 

cylinder  until  the  vein  coHapsed  or  releasing  the  air  until  the  vein 
refilled.  This  method  was  improved  upon  by  von  Recklinghausen/ 
and  later  by  Hooker  and  Eyster,^  so  as  to  reduce  the  error  caused 
by  pressure  of  the  wall  of  the  cylinder  against  the  vein.  The  latter 
authors  compared  readings  made  with  a  manometer  in  the  facial 
vein  of  a  dog  with  those  made  with  their  instrument  over  the  neigh- 
boring exposed  external  jugular.  The  pressure  was  artificially 
altered  by  tilting  the  animal's  body.    The  results  follow: 

Manometer  in  Pressure  chamber  over 

Observation.  facial  vein.  external  jugular. 

1 4.5  cm.  H2O  4  cm.  H2O 

2 10.0  cm.  H2O  10  cm.  H2O 

3 13.0  cm.  H2O  14  cm.  H2O 

4  . 5.0  cm.  H2O  5  cm.  H2O 

A  further  improvement  of  this  instrument  has  been  made  by 
Hooker/  and  in  its  present  form  the  instrument  has  proved  most 
satisfactory.  Two  conditions  are  necessary  for  its  use :  First,  that 
the  vein  shall  stand  out  sufficiently  from  the  surrounding  skin 
level  to  give  a  distinct  shadow  by  oblique  illumination,  and,  second, 
that  the  vein  wall  must  be  collapsible.  Hence  "old  patients  with 
phlebosclerosis,  patients  with  exceedingly  edematous  or  fat  hands, 
and  patients  with  continuously  small  veins  are  not  satisfactory 
for  this  method"  (Clark), 

IV.  "Double-cufE  Manometers  (Fig.  67). — In  1912  two  instruments 
upon  the  same  principle  were  introduced  independently,  one  by 
L.  Frank  and  M.  Reh*  and  the  other  by  A,  A,  Howell,^  The  instru- 
ments consist  of  two  cuffs,  each  attached  to  a  water  manometer. 
One  cuff  is  applied  to  the  upper  arm,  the  other  to  the  forearm. 
The  forearm  cuff  is  inflated  so  as  to  fit  against  the  arm  snugly 
without  exerting,  however,  more  than  1  cm.  (Frank  and  Reh)  to 
3  cm.  (Howell)  H2O  pressure.  The  upper  cuff'  is  then  slowly  inflated 
until  the  water  in  the  forearm  manometer  is  seen  to  be  rising.  This 
rise  is  assumed  to  be  evidence  that  the  venous  flow  beneath  the 
upper  cuff  has  been  obstructed  and  that  the  blood,  being  dammed 
back,  has  increased  the  volume  of  the  forearm  with  consequent 
displacement  of  air  from  the  lower  cuff  and  a  rise  of  water  in  its 
attached  manometer.  The  forearm  cuff  and  its  manometer  are 
used,  therefore,  as  a  sort  of  plethysmograph.  It  is  further  assumed 
that  the  blood  flow  beneath  the  upper  cuff  is  first  obstructed  when 

1  Arch.  f.  exper.  Path.  u.  Pharm.,  1906,  Iv,  463. 

2  Johns  Hopkins  Hosp.  Bull.,  1908,  xix,  274. 
'  Am.  Jour.  Physiol.,  1914,  xxxv,  73. 

*  Ztschr.  f.  expcr.  Path.  u.  Therap.,  Berlin,  1912,  x,  241. 
5  Arch.  Int.  Med.,  1912,  ix,  148. 


INTRAVENOUS  NEEDLE 


143 


the  pressure  in  this  cuff  equals  the  venous  pressure.  The  instrument 
of  Frank  and  Reh  differs  from  Howell  in  that  it  provides  for  graphic 
registration  of  the  readings.  Reference  to  the  table  on  p.  146 
shows  that  Howell's  figures  are  somewhat  higher  than  those  of 
Frank  and  Reh,  which  may  be  in  part  explained  by  the  higher 
pressure  used  by  Howell  in  his  plethysmographic  cuff. 


Fig.  67. — ^Howell's  venous  pressure  apparatus.  Upper  and  lower  cuffs  applied 
and  attached  to  their  respective  water  columns.  E,  light  cuff  for  constricting  upper 
arm  and  obstructing  venous  return ;  F,  glass  T  and  bulb,  by  means  of  which  pressure 
is  raised  in  E;  G,  water  column  measuring  pressure  in  E;  B,  inelastic  covering  of 
light  material  encircling  rubber  bag;  C,  glass  T,  side  tube,  and  clip,  by  means  of  which 
pressure  can  l^e  raised;  D,  water  column  measuring  pressure. 


V.  Intravenous  Needle. — In  1909-10  Moritz  and  von  Tabora^ 
published  studies  of  venous  pressure  measured  by  the  pressure 
required  to  cause  normal  saline  to  enter  the  median  vein  at  the  level 
of  the  heart.  The  method  was  to  place  the  patient  in  the  recumbent 
position,  and  then  introduce  into  the  median  vein  with  the  usual 
precautions  a  needle  connected  with  a  burette  of  normal  saline. 
The  saline  was  allowed  to  enter  the  vein,  its  level  in  the  burette 
falling  until  further  flow  ceased.  The  level  of  the  saline  above  the 
heart  was  then  read,  and  the  resulting  figure  was  assumed  to  be  the 
venous  pressure  at  the  heart  in  centimeters  normal  saline,  which 
since  10  cm.  normal  saline  equals  10.07  cm.  H2O  may  be  reckoned 
as  cm.  H2O.     In  all  the  other  methods  described  the  patient  is 

>  Deutsch.  Arch.  f.  kliu.  Med.,  1909-10,  xcviii,  475. 


144 


VENOUS  BLOOD-PRESSURE 


in  sitting  posture,  and  the  level  of  the  heart  is  by  most  observers 
taken  according  to  von  Recklinghausen's  rule  as  at  the  level  of 
the  apex  of  the  subcostal  angle.  With  the  patient  recumbent 
Moritz  and  von  Tabora  assun[ie  the  heart  level  to  be  that  of  a 
point  on  the  fourth  rib  5  cm.  below  the  level  of  the  anterior  thoracic 
surface.  This  method  of  measuring  venous  pressure  is  the  most 
accurate  of  those  described  for  use  in  man. 


Fig.  68. — The  Moritz-Taboru  venous  blood-pressure  apparatus:     A,  cannula  in  vein; 
B,  manometer  scale;  C,  level;  D,  escapement.     (After  Hoffmann.) 


Capillary  Pressure. — In  1875  the  attempt  to  measure  capillary 
pressure  was  first  made  by  von  Kries.^  A  small  glass  plate  of 
known  area  was  laid  upon  the  skin  or  mucous  membrane  and 
pressure  was  exerted  evenly  upon  it  by  means  of  delicate  weights. 

1  Berichte  u.  d.  Verhandlung  der  koniglich  sachsisch,  Gesellschaft  d.  Wissen- 
schaften  z.  Leipsic  math.  Phya.,  1875,  clxxvii,  147. 


CAPILLARY  PRESSURE  145 

The  amount  of  weight  required  to  produce  a  just  perceptible 
pallor  of  the  skin  or  mucous  membrane  was  taken  to  be  the  capillary 
pressure,  and  the  weight  and  area  over  which  it  acted  being  known, 
the  pressure  per  unit  of  area  and  hence  the  pressure  in  millimeter 
Hg.  (1  mm.  Hg.  =  0.0136  gm.  per  square  millimeter)  or  in  centi- 
meter H2O  (1  cm.  H2O  =  0.01  gm.  per  square  millimeter)  can  be 
calculated.  Von  Basch  and  von  Recklinghausen  measured  capillary 
pressure  with  the  same  apparatus  employed  for  measuring  venous 
pressure  by  applying  it  over  a  skin  area,  the  former  noting  the  press- 
ure required  to  just  cause  complete  blanching,  the  latter  raising 
the  pressure  above  the  point  required  to  produce  complete  pallor, 
and  on  gradually  lowering  the  pressure  noting  the  moment  when 
flushing  first  became  apparent  and  also  when  flushing  became 
complete. 

Lombard^  has  recently  developed  a  refinement  of  these  methods. 
He  finds  that  if  the  skin  be  wet  with  glycerin  or  with  a  transparent 
oil,  by  the  use  of  a  low-power  magnification  (from  10  to  35 
diameters),  and  either  bright  daylight  or  a  Nernst  lamp,  the  papillae 
of  the  skin  with  their  superficial  bloodvessels  are  rendered  visible. 
He  applies  this  method  either  with  a  weighted  glass  plate  according 
to  von  Kries,  or  with  a  specially  constructed  chamber  similar  in 
general  principle  to  von  Recklinghausen's.  Lombard's  chamber 
coiisists  of  an  inverted  truncated  cone.  The  smaller  end,  which 
fits  against  the  skin,  has  a  diameter  of  24  mm.,  its  walls  are  3  mm. 
thick,  and  the  pressure  is  therefore  applied  over  a  circular  area 
of  18  mm.  in  diameter.  Over  the  periphery  of  this  area  the  skin  is 
covered  by  a  rubber  dam,  which  aids  in  preventing  leakage  between 
the  chamber  and  skin.  A  central  circular  area  5  mm.  in  diameter 
is  left  open  for  inspection  through  the  microscope.  In  using  the 
von  Kries  plate,  Lombard  has  found  the  optimum  dimension  for 
his  purposes  to  be  1  mm.  square.  If  larger  plates  be  used,  the 
weight  is  borne  disproportionately  at  the  edges.  Lombard  has 
shown,  as  may  be  seen  in  the  following  table,  great  variation  in 
pressure  in  capillaries  of  different  sizes.  The  measurement  of 
capillary  pressure  in  individuals  or  in  pathological  conditions  can 
hardly  be  of  value,  therefore,  while  we  lack  means  of  discriminating 
between  the  particular  type  of  capillary  under  consideration. 
Inspection  of  the  table  suggests  that  the  grosser  methods  of  von 
Kries,  von  Basch,  and  von  Recklinghausen  measure  the  pressure 
in  the  medium-sized  and  larger  capillaries  on  the  arterial  side. 

» Am.  Jour.  Physiol.,  1912,  xxix,  335. 
10 


146 


VENOUS  BLOOD-PRESSURE 


Level  of  heart. 

Capillary  pressure. 

Cm.  HtO. 

Mm.  Hg. 

von  Kries,  finger,  first  pallor 

.      .      .                   51.3 

37.7 

von  Basch,  hand,  complete  pallor    . 

34.0  to  41.0 

25.0  to  30.0 

von  Recklinghausen,  hand,  first  flush    . 

93.0  to  99.0 

68.0  to  72.5 

von  Recklinghausen,  hand,  complete  flush 

75.0 

55.1 

Lombard — Largest  capillaries 

82.0  to  95.0 

60.0  to  70.0 

"            Medium  capillaries    . 

48.0  to  61.0 

35.0  to  45.0 

"            Smallest  capillaries,  back  of  hand 

20.6  to  30.9 

15.1  to  22.7 

"            Smallest  capillaries,  finger-nai 

23.3  to  37.5 

17 . 1  to  27 . 6 

"            Most  superficial  and  smallest 

veins 

20.5  to  27.0 

15.0  to  20.0 

"            Subpapillary  venous  plexus 

13.5  to  20.5 

1-0.0  to  15.0 

At  level  of  heart. 

Normal,                              Pathological. 

Venous  pressure.               Cm.  H»0. 

Mm.  Hg.              Cm.  HjO. 

Mm.  Hg. 

Sewell 4.6  to    5.2 

3.4  to  3.8 

von  Basch  ....         '             8.8 

6.5 

von  Recklinghausen: 

filled     ....      14.0  to  22.0 

empty        .      .      .      20.0  to  26.0 

Hooker-Eyster       .      .        3.0  to  10.0 

2.2  to  7.3 

av.  8.0 

av. 5.9 

Frank  and  Reh      .      .        1.0  to    6.0 

0.7  to  4.4                    17.0 

12.5 

HoweU 4.0  to  13.0 

2.9  to  9.5           7  to  25.0 

5.1  to  18.4 

av. 7.6 

av.  5.6             av.  13.9 

av.  10.2 

Moritz  and  Tabora     .        1.1  to    8.7 

0.8  to  6.4 

av.  5 . 2 

av.  3.8 

Summary    .      .      ,      .        1.0  to  13.0 

0.7  to  9.5         up  to  25.0 

up  to  18  + 

VARIOUS  FACTORS  INFLUENCING  VENOUS  PRESSURE. 

The  position  of  a  part  with  relation  to  the  heart  is  probably  the 
most  important  factor  in  determining  venous  pressure.  The  weight 
of  the  blood  is  such  that  the  pressure  of  one  inch  of  blood  is  approxi- 
mately equal  to  1.9  mm.  Hg.  or  2.6  cm.  H2O.  It  has  been  shown, 
however,  by  von  Recklinghausen  that  the  veins  of  the  feet  do  not 
actually  exhibit  the  pressure  demanded  by  calculation  upon  this 
basis.     This  is  shown  in  the  following  table: 

Venous  Pressure  at  Various  Levels. 

(Data  from  von  Recklinghausen.) 

Distance 
below     In  cm.  H2O  In   mm.   Hg. 

heart  in    calculated.    Measured.  calculated.  Measured, 

inches. 

Heart 10  ..  7.3 

Symphysis  pubis,  sub- 
ject sitting  or  stand- 
ing           12  42  ..  31.0 

Foot,  subject  sitting   .     34  102  55  to    80  75.0  40.0  to  59.0 
Foot,  subject  standing    48             140            79  to  100           103.0  58.0  to  73.0 
Foot,    subject    recum- 
bent   0               10               8  to    10               7,3  5.9  to    7.3 


This  discrepancy  von  Recklinghausen  supposes  to  be  due  to 
the  action  of  the  muscle  masses  of  the  extremities  which,  by  their 


VARIOUS  FACTORS  INFLUENCING  VENOUS  PRESSURE     147 

intermittent  pressure  upon  the  veins,  aided  by  the  action  of  the 
valves  of  the  veins,  serve  to  propel  the  blood  up  into  the  vena  cava, 
where  he  supposes  the  venous  pressure  actually  exhibits  its  cal- 
culated value.  This  importance  of  muscular  activity  in  promoting 
the  return  of  venous  blood  from  the  extremities  may  explain  in 
part  the  discomfort  incident  to  prolonged  standing  in  one  position. 
The  importance  of  position  in  the  determination  of  venous  pressure 
is  further  shown  by  the  fact  that  raising  one  arm  above  the  level 
of  the  head  increases  the  venous  pressure  in  the  opposite  arm. 

Barach  and  Marks^  have  noted  that  readings  of  venous  pressure 
in  the  arm  do  not  always  show  a  constant  relative  difference  pro- 
portional to  the  elevation  or  depression  above  or  below  the  level 
of  the  right  auricle.  Hence  venous  pressure  should  be  measured 
at  the  level  of  the  right  auricle  rather  than  at  another  level  followed 
by  correction  to  the  level  of  the  auricle. 

Changes  in  arterial  pressure  do  not  readily  alter  the  venous  press- 
ure. The  capillary  pressure,  at  least  of  the  smaller  capillaries,  is 
much  more  dependent  upon  venous  than  upon  arterial  pressure. 
Hooker  finds  that  there  is  no  relation  between  venous  pressure  and 
changes  in  pulse  rate,  and  that  local  changes  in  vascular  tone  (cold, 
heat,  etc.),  do  not  alter  the  venous  pressure  in  the  hand.  Burton- 
Opitz^  was  able  to  show  only  a  very  slight  fall  of  venous  pressure 
in  the  external  jugular  of  a  dog  upon  occluding  a  portion  of  the 
arterial  supply  to  the  head. 

Normal  Venous  Pressure  at  the  level  of  the  right  auricle  was  found 
by  Barach  and  Marks  to  range  in  the  erect  posture  between  8  and 
18  cm.  H2O  and  in  the  recumbent  posture  between  3.5  and  11  cm. 
H2O.  Muscular  exertion  either  general  or  local  was  found  by 
Hooker  and  Wolfsohn,^  Elfers^  and  Schott,^  to  increase  the  venous 
pressure  from  a  slight  rise  up  to  14  cm.  H2O.  Hooker^  has  noted 
a  distinct  diurnal  variation  under  normal  conditions  of  health  even 
in  individuals  confined  to  bed.  He  observes  a  gradual  rise  through- 
out the  day  from  10  to  20  cm.  H2O  to  an  average  diurnal  pressure 
of  15  cm.  and  a  fall  during  sleep  to  as  low  as  7  to  8  cm.  During 
sleep  he  has  noted  a  venous  pulse  of  peripheral  origin  in  the  veins 
of  the  hands.  Clark^  found  in  4  bed  patients  without  cardiac 
complications,  a  durnal  variation  of  from  8  to  10  cm.  H2O,  the 
maximum  (10-16  cm.)  being  reached  from  2  to  8  p.m.,  and  the 

1  Arch.  Int.  Med.,  1913,  xi,  485.  «  Am.  Jour.  Physiol.,  1903,  ix,  198. 

» Ibid.,  1909-10,  XXV,  24;  1911,  xxviii,  235. 

<Inaug.  Diss.,  Kiel,  1911. 

6  Deutsch.  Arch.ff.  klin.  Med.,  1912,  cviii,  537. 

6  Am.  Jour.  Physiol.,  1914,  xxxv,  73.  '  Arch.  Int.  Med.,  1915,  xvi,  587. 


148  VENOUS  BLOOD-PRESSURE 

minimum  (5-8  cm.)  between  10  p.m.  and  6  a.m.  This  author  from 
repeated  observation  on  14  cases,  6  with  decompensation,  8  with 
good  compensation,  concludes  that  a  venous  pressure  above  twenty 
is  pathological.  In  cardiac  cases,  the  diurnal  variation  was  found 
by  Clark  to  be  reversed,  the  highest  pressure  occurring  during  the 
sleeping  hours.  Venous  pressure  continuously  above  20  cm.  which 
was  not  lowered  by  digitalis,  was  an  indication  of  grave  cardiac 
involvement.  On  the  other  hand,  with  a  venous  pressure  below 
20  cm.  no  definite  change  in  the  pressure  was  observed  from  digitalis 
therapy.  The  venous  pressure  and  the  urinary  output  generally 
showed  a  significant  inverse  variation  in  cases  of  cardiac  decom- 
pensation. Aspiration  of  pleural  fluid  and  venesection  both  lowered 
venous  pressure  as  a  rule  in  his  series,  but  after  the  latter  procedure 
the  subsequent  rise  of  venous  pressure  was  rapid. 

Effect  of  Age  on  Venous  Pressure.^ — Hooker^  has  found  the  venous 
pressure  to  be  lower  in  boys  than  in  men  of  mature  years.  The 
following  table  gives  the  results  of  his  observations  on  a  series  of 
cases  including  fifty  observations  in  each  decade  of  life.  The 
pressures  are  expressed  in  centimeters  of  water,  referred  to  the  level 
of  the  heart,  and  the  range  of  the  individual  observations  and  the 
averages  are  tabulated: 

Venous  pressure. 
Years  Minimum. 

5  to  15 4 

15  to  25 5 

25  to  35     .      . 10 

35  to  45 10 

45  to  55 10 

55  to  65 11 

65  to  75 16 

75  to  85 14 

These  subjects  were  up  and  about  and  not  confined  to  bed. 
Hooker  used  his  method  described  on  page  141  and  took  as  the  end- 
point  the  complete  collapse  of  the  vein,  whereas  Clark  (v.  s.)  used 
as  the  end-point  the  pressure  at  which  the  shadow  of  the  vein  comes 
and  goes  with  slight  oscillations  of  pressure.  The  latter  is  probably 
a  more  accurate  method  and  gives  somewhat  lower  values,  but  is  a 
more  difficult  end-point  to  determine. 

Effects  of  Exercise. — Hooker  has  also  studied  the  effect  of  exercise 
upon  venous  pressure,  making  a  reading  before  and  a  few  minutes 
after  a  competitive  run,  or  during  exercise  upon  a  stationary 
bicycle.  The  results  in  a  series  of  individuals  are  shown  in  the 
following  tabulation : 

I  Am.  Jour.  Physiol.,  1916,  xl,  43. 


15 

8.30 

22 

22.66 

31 

15.0 

29 

17.98 

29 

19.04 

35 

24.17 

39 

25.59 

35 

26.0 

VARIOUS  FACTORS  INFLUENCING  VENOUS  PRESSURE    149 

Venous  pressure. 
Before  After 

Age  -  exercise.  exercise. 

26 8  20 

19  ...   .      12  24 

20 15  24 

20 10  24 

39 11  28 

29 32 

Schneider  and  Sisco^  studied  the  venous  pressure  of  six  subjects 
by  the  method  of  Hooker  and  Eyster  at  altitudes  of  6000  and  14,109 
feet.  At  the  lower  altitude  they  found  in  17  men  an  average  venous 
pressure  of  about  16  cm.  of  water.  In  5  out  of  6  subjects  the  venous 
pressure  was  lower  at  the  higher  altitude  by  from  25  to  87  per  cent., 
in  2  of  the  subjects  being  at  times  slightly  negative.  In  a  later 
study^  they  have  shown  that  physical  work  causes  a  greater  rise 
in  the  venous  pressure  at  the  higher  altitude  than  at  the  lower 
altitude  or  at  sea  level,  but  in  spite  of  this  fact  the  maximum  pressure 
reached  is  usually  less  than  at  the  low  altitude  because  of  the  lower 
initial  venous  pressure  when  at  rest  at  the  high  altitude. 

Respiration. — Burton-Opitz  made  careful  studies  of  the  effect 
of  respiration  upon  the  venous  pressure  in  the  external  jugular  of 
a  dog,  and  found  that  with  expiration  the  jugular  pressure  rose 
and  that  during  the  pause  following  expiration  it  began  to  fall  and 
continued  to  fall  throughout  the  early  part  of  inspiration,  a  curve 
similar,  there/ore,  to  that  of  the  arterial  pressure  in  the  respiratory 
phases.  Upon  expiration  the  intrathoracic  pressure  rises  and  the 
venous  blood  does  not  readily  enter  the  thorax,  but  being  dammed 
back  causes  rise  of  peripheral  venous  pressure.  I  pon  inspiration 
the  intrathoracic  pressure  falls  and  the  venous  blood  flows  readily 
into  the  thorax,  with  fall  in  the  peripheral  venous  pressure;  near 
the  thorax  the  venous  pressure  may  be  negative  during  inspiration. 
The  respiratory  variation  found  in  the  external  jugular  pressure 
is  as  much  as  3.8  cm.  H2O,  and  becomes  greater  as  the  thorax  is 
approached.  The  opening  of  the  thorax  by  increasing  the  intra- 
thoracic pressure  (which  is  normally  less  than  the  atmospheric) 
causes  a  prompt  rise  of  venous  pressure  of  from  1.5  to  3.5  cm.  IT2O. 

Cardiac  Action. — Impaired  cardiac  action  by  leading  to  venous 
stasis  produces  an  increase  of  venous  pressure.  Experimentally, 
stimulation  of  the  peripheral  end  of  the  sectioned  vagus  produces 
a  slight  rise  of  venous  pressure.  Clinically,  any  form  of  myocardial 
decompensation  leads  to  increase  of   venous  pressure  which  may 

>  Am.  Jour.  Physiol.,  1914,  xxxiv,  1. 
'  Ibid.,  1916,  xl,  380. 


150  VENOUS  BLOOD-PRESSURE 

rise  to  30  cm.  II2O  in  the  veins  of  the  arm  at  the  cardiac  level. 
Indeed,  increased  venous  pressure  may,  in  the  early  stages,  be  the 
only  sign  of  circulatory  stasis. 

Intravenous  Injection.— That  intravenous  injections  increase  the 
venous  pressure  more  proportionately  than  they  do  the  arterial 
was  shown  by  Bayliss  and  Starling.^  Rise  of  venous  pressure  at  the 
heart  also  results  from  abdominal  pressure,  bandaging  or  elevation 
of  the  extremities,  or  from  elevation  of  the  abdomen  above  the 
level  of  the  heart.  The  importance  of  venous  pressure  in  relation 
to  cardiac  output  has  already  been  discussed.  Experimentally 
as  a  result  oi  therapeusis,  a  rise  of  venous  pressure  occurs  after  large 
doses  of  epinephrin,  pituitrin,  and  alcohol,  not  after  digitalis, 
strophanthin,  strychnin  or  caffein.  This  rise  is  proportionate  to, 
and  apparently  the  result  of  disturbed  heart  action.  It  is  therefore 
apparently  simply  a  stasis  reaction  and  not  the  result  of  vasomotor 
influence.  A  fall  of  venous  pressure  may  follow  the  administration 
of  the  nitrites  or  large  doses  of  morphin,  and  since  cardiac  func- 
tionation  remains  unimpaired,  may  be  attributed  to  a  direct 
influence  on  the  vasomotor  mechanism.^ 

1  Jour.  Physiol.,  1894,  xvi,  159. 

"  Capps,  J.  A.,  and  Mathews,  S.  A.:  Venous  Blood-pressure  as  Influenced  by  the 
Drugs  Used  in  Cardiovascular  Therapy,  Jour.  Am.  Med.  Assn.,  1913,  Ixi,  388. 


CHAPTER  V. 

THE  FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

AS  DETERMINABLE  BY  BLOOD-PRESSURE 

ESTIMATION  AND  ALLIED  TESTS. 

In  the  following  chapter  are  described  a  number  of  methods 
which  have  been  suggested  in  the  hope  of  throwing  more  light  on 
the  question  of  the  functional  efficiency  of  the  circulation.  Most 
of  them  are  based  on  sound  theoretic  principles,  and  would  be 
invaluable  if  our  instrumental  measurements  were  sufficiently 
exact  and  comprehensive  to  insure  an  accurate  basis  for  our  deduc- 
tions. Unfortunately,  however,  the  data  obtainable  by  sphygmo- 
manometry,  etc.,  are,  even  when  collated  with  the  greatest  care, 
subject  to  unavoidable  sources  of  error,  and  hence  our  results  are 
only  approximate.  To  use  such  data  as  a  basis  for  elaborate 
calculations,  entailing  the  use  of  involved  mathematic  and  algebraic 
formulae  for  the  elucidation  of  the  complex  factors  included  in  the 
static  and  dynamic  laws  of  the  circulation,  only  magnifies  our  errors 
and  often  leads  to  a  veritable  reductio  ad  ahsurdum.  Thus  far  it 
must  be  admitted  no  entirely  satisfactory  method  has  been  perfected, 
mainly  because  we  cannot  measure  vascular  tonus,  or  estimate 
the  role  of  psychic  processes.  Furthermore,  to  yield  definite 
indications  many  of  the  tests  have  to  be  carried  to  a  point  at 
which  concomitant  symptoms  and  ordinary  physical  signs  are  of 
themselves  sufficiently  evident  criteria  of  functional  insufficiency. 
Unquestionably,  however, .  some  of  the  methods  about  to  be  de- 
scribed do  throw  a  useful  light  on  the  problem  under  consideration, 
especially  if  the  results  thus  obtained  are  accepted  with  due  reserve. 

j\Iany  are  the  attempts  which  have  been  made  and  numerous 
the  methods  suggested  for  determining  the  functional  capacit}^ 
of  the  heart.  The  importance  of  this  subject  from  a  diagnostic, 
prognostic,  and  therapeutic  stand-point  cannot  be  overestimated. 
Such  procedures  as  are  based  in  part,  at  least,  upon  blood-pressure 
measurements  will  be  here  considered. 

Generally  speaking,  such  tests  depend  upon  the  way  in  which 
the  pulse  rate  and  blood-pressure  both  respond — quantitatively. 


152      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

qualitatively,  and  temporarily — to  definite  amounts  of  muscular 
exertion  or  to  change  of  posture  (see  p.  5-1).  This  subject  has  been 
extensively  studied  by  Masing,  Buttermann,  Christ,  Staehelin,  and 
others.^  The  work  performed  w^s  either  definitely  measured  with 
various  forms  of  apparatus,  or  roughly  estimated  by  such  tasks  as 
lifting,  stair-climbing,  walking,  etc. 

"In  blood-pressure  and  exercise  we  have  an  unfailing  guide  to 
the  true  condition.  Whatever  the  abnormality,  the  great  question 
is  the  integrity  of  the  heart  muscle,  the  reserve  force  of  the  heart, 
for  upon  this  chiefly  depends  the  prognosis.  The  pulse  should  be 
counted,  the  heart  examined,  and  the  blood-pressure  taken,  and 
then  with  the  cuff  attached  to  the  arm,  the  applicant  should  be 
exercised  to  the  equivalent  of  climbing  two  flights  of  stairs  and 
then  reexamined  quickly.  Exercise  when  not  too  severe  will  regu- 
late the  pulse  if  the  condition  is  simple.  If  serious  disease  is  present 
the  irregularity  will  be  greatly  increased.  If  the  heart  muscle  is 
in  prime  condition  the  systolic  pressure  will  jump  15  to  40  mm. 
and,  tested  every  two  minutes,  will  be  found  to  resume  its 
original  place  in  six  to  eight  minutes.  If  the  condition  is  bad,  in 
a  powerful  effort  of  the  heart  to  respond,  the  rise  may  be  even 
greater,  but  the  return  will  be  exceedingly  slow,  sometimes  requir- 
ing twenty  to  thirty  minutes.  If  the  state  of  the  muscle  is  ex- 
tremely bad  and  the  reserve  force  exhausted,  the  systolic  pressure 
may  fall  instead  of  rising  and  the  diastolic  remain  stationary,  or 
rise  a  little,  creating  a  very  small  pulse-pressure.  It  will  be  a  long 
time  before  graphic  instrument  tracings  are  required  in  life  insur- 
ance, if  ever,  but  we  have  in  exercise  and  blood-pressure  a  thor- 
oughly reliable  test,  and  it  is  the  duty  of  the  examiner  to  be  safe 
in  his  recommendation  of  every  applicant.""^ 

Crampton's  Test  of  Vasomotor  Efl&ciency.^In  rising  from  the 
recumbent  to  the  erect  posture  blood-pressure  tends  to  fall  as  a 
result  of  gravity.  Unless  this  tendency  were  automatically  regu- 
lated, syncope  would  occur  as  a  result  of  cerebral  anemia.  In  a 
normal  vigorous  man,  however,  such  a  change  of  position  causes  a 
rise  of  blood-pressure  amounting  to  8  to  10  mm.  Hg.  This  increase 
may  result  from  increased  vasomotor  tone  or  from  increased  cardiac 
work,  or  as  a  result  of  both  factors.  Bearing  these  facts  in  mind 
Crampton^  has  devised  the  following  table  to  test  vasomotor  effi- 

1  For  bibliography,  see  Norris,  G.  W. :  The  Functional  Capacity  of  the  Heart. 
Intornat.  Clinics,  1907,  17th  series,  vol.  i. 

2  Lankford,  J.  S. :    The  Heart  in  Life  Insurance,  Med.  Rec,  October  17,  1914,  p.  687. 
'  Blood  Ptosis,  New  York  Med.  Jour.,  November  8,  1913. 


CRAMPTON'S  TEST  OF  VASOMOTOR  EFFICIENCY       153 

ciency  through  the  observation  of  pulse  rate  and  blood-pressure 
responses  to  postural  change.  The  tables  while  setting  what  is 
perhaps  a  high  normal  have  shown  that  vasomotor  tone  in  the  same 
individual  varies  greatly  as  a  result  of  mental  or  physical  fatigue, 
infectious  processes,  etc.  It  may  be  used  with  especial  edification 
in  the  study  of  essential  hypotension  cases. 

The  Technic. — "The  sphygmomanometer  is  adjusted  over  the 
brachial  artery  and  the  patient  is  placed  on  a  comfortable  couch 
with  a  low  pillow.  The  heart  rate  is  counted  by  quarter-minutes 
and  a  gradually  decreasing  rate  is  usually  observed.  Counting 
should  continue  until  two  successive  quarter-minutes  are  the  same, 
this  is  multiplied  by  4  and  recorded.  The  systolic  pressure  is  then 
taken  preferably  by  auscultation.  The  patient  stands,  the  heart 
rate  is  counted  as  before  until  it  reaches  the  'standing  normal,' 
when  it  is  recorded,  and  the  blood-pressure  is  then  taken.  The 
differences  are  calculated  and  reference  is  made  to  the  scale. 

"For  example — Case  XX:  L.  V.,  age  seventeen  years,  said  to 
be  in  good  condition  at  11:20  a.m. 

Pulse  rate.        Blood-pressure. 

Horizontal ' 68  100 

Vertical ; 104  94 

Difference .      -^-36  -6 

Percentage  record,  20. 

"This  is  a  very  poor  record  taken  from  an  apparently  normal, 
strong  young  football  player  of  exceptional  ability  who  had  previ- 
ously given  records  above  80. 

"  I  was  at  a  loss  to  account  for  this,  for  questioning  failed  to  bring 
out  any  history  of  loss  of  sleep,  dissipation,  or  illness.  He  looked 
quite  as  'fit'  as  usual.  He  was  absent  next  day,  and  remained 
home  for  a  week  with  a  '  cold  and  fever.'  It  is  evident  that  the  test 
revealed  a  weakened  vasotone,  the  beginning  of  actual  illness  before 
any  other  symptom  could  be  noted.  Others  who  have  used  this 
test  have  noted  similar  cases." 

If  the  vasomotor  tone  is  deficient,  the  heart  must  make  up  for 
it  by  an  increase  in  rate — the  greater  the  increase,  the  less  efficient 
the  vasomotor  tone. 

"The  usual  range  of  the  systolic  pressure  is  from  -flO  to  —10 
of  the  heart-rate  increase  from  0  to  44,  as  observed  from  records  of 
a  large  number  of  cases.  Upon  a  statistical  balancing  of  these  two 
series  of  frequencies,  and  assigning  equal  percentages  to  equal 
ranges,  the  following  scale  is  constructed : 


154      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 


PERCENTAGE   SCALE. 


Vasomotob  Tone. 

Blood-pressure. 

Heart-rate 
increase. 

Increase 

^ 

Decrease 

+10 

+8 

+6 

+4 

+2                   0 

-2 

-4 

-6 

-8 

-10 

0  to    4     . 

100 

95 

90 

85 

80             75 

70 

65 

60 

55 

50 

5  to    8     . 

95 

90 

85 

80 

75             70 

65 

60 

55 

50 

45 

9  to  12     . 

90 

85 

80 

75 

70             65 

60 

55 

50 

45 

40 

13  to  16     . 

85 

80 

75 

70 

65             60 

55 

50 

45 

40 

35 

17  to  20     . 

80 

75 

70 

65 

60             55 

50 

45 

40 

35 

30 

21  to  24     . 

75 

70 

65 

60 

55             50 

45 

40 

35 

30 

25 

25  to  28     . 

70 

65 

60 

55 

50             45 

40 

35 

30 

25 

20 

29  to  32     . 

65 

60 

55 

50 

45             40 

35 

30 

25 

20 

15 

33  to  36     . 

60 

55 

50 

45 

40             35 

30 

25 

20 

15 

10 

37  to  40     . 

55 

50 

45 

40 

35             30 

25 

20 

15 

10 

5 

41  to  44     . 

50 

45 

40 

35 

30             25 

20 

15 

10 

5 

0 

Note. — In  case  of  increase  in  pressure  higher  than  -f  10  add  5  per  cent,  to  the 
+10  column  for  each  2  millimeters  in  excess  of  10. 

"This  scale  provides  a  convenient  and  intelligible  method  of 
recording  and  reporting  cases  and  permits  a  numerical  statement 
of  the  function  in  question.  Its  100  mark  indicates  a  perfectly 
efficient  working  of  the  vasomotor  system  under  test,  the  zero  is 
approximately  the  point  where  the  average  person  is  unable  to 
maintain  the  erect  posture." 

Among  116  athletes  R.  Tait  McKenzie  found  the  postural  change 
in  pulse  rate  and  systolic  blood-pressure  average  as  follows: 


Number  of 
students. 

Lying. 

Pulse. 

Standing. 

Blood 
Lying. 

pressure. 
Standing 

34   .      .      .      . 

...      78 

86 

114 

113 

28  ...      . 

...     75 

85 

120 

121 

30  ...      . 

...     83 

85 

120 

114 

24  ...      . 

.      .      .     70 

79 

110 

114 

116  .      .      .      . 

...     77 

84 

116 

115 

It  will  be  noted  that  there  was  a  very  constant  variation  in  the 
pulse  rate  amounting  to  about  seven  beats  per  minute  between  the 
two  postures.  The  blood-pressure  findings  were  much  more  variable 
and  when  an  average  was  established  they  were  practically  identical 
in  the  two  positions.  Among  388  students  with  cardiac  abnormal- 
ities— arrhythmia,  murmurs,  etc. — the  systolic  blood-pressure  aver- 
age was  somewhat  higher  (138 -|-  mm.  Hg.)  than  among  the -athletes 
with  normal  hearts. 

Passive  change  of  posture. 

"When  the  element  of  muscular  effort  has  been  eliminated, 
change  of  bodily  posture  from  the  erect  to  the  horizontal  will  cause 
an  increase  in  the  maximmn  pressure,  a  decrease  in  the  minimum 


CRAMPTON'S  TEST  OF   VASOMOTOR  EFFICIENCY       155 

pressure,  and  an  increase  in  the  pulse-pressure.  After  five  minutes 
in  the  horizontal  posture  when  the  subject  is  retilted  to  the  erect 
posture,  the  maximum  pressure  will  diminish,  the  minimum  pressure 
increase  and  the  pulse-pressure  diminish.  It  will  be  noted  that  in 
both  instances  the  pulse-pressure  follows  the  same  trend  as  the 
maximum  pressure.  Change  of  posture  from  the  erect  to  the  hori- 
zontal causes  a  fall  in  the  venous  pressure.  Change  of  posture  from 
the  horizontal  to  erect  causes  an  increase  of  the  venous  pressure."^ 
Among  twenty  healthy  young  adults  change  of  posture  yielded 
the  following  results : 


Systolic  pressure. 

Standing. 

Sitting. 

Supine. 

Head 
down. 

Right 
lateral. 

Left 
lateral. 

Right  arm 

.      132.6 

133.3 

152.5 

166.2 

155.0 

110.0 

Average     . 

.      130.8 

131.7 

150.4 

165.6 

143.5 

133.0 

Left  arm    . 

.      130.0 

130.0 

148.3 

165.0 

141.0 

156.0 

Pulse  rate 

.       86.0 

82.0 

68.7 

65.8 

68.1 

69.1 

In  other  words,  "Blood-pressure  increases  in  the  brachial  arteries 
from  the  standing  to  the  head-down  position,  inclusively  in  the 
following  order:  standing,  sitting,  left  lateral,  right  lateral,  supine, 
head  down."^ 

During  muscular  exercise  we  see  an  increased  respiratory  gas 
interchange,  the  amount  of  which  may  exceed  that  occurring  dur- 
ing rest  over  twentyfold.  Associated  with  this  there  is  a  marked 
increase  in  the  rate  of  blood  flow,  so  that  the  normal  circulation, 
the  time  of  which  is  fifty-five  seconds,  may  be  reduced  to  five 
seconds  during  exercise.  Such  changes  must,  of  course,  produce 
enormous  alterations  in  blood-pressure  values. 

Muscular  exertion  may  be  accompanied  either  by  a  fall  or  by  a 
rise  of  pressure,  and  it  has  been  found  that  the  more  fit  and  well- 
trained  the  animal  the  less  the  tendency  for  the  pressure  to  rise. 
Thus  in  horses  and  in  well-trained  athletes  there  is  a  fall.  The 
average  man  shows  a  primary  rise,  followed  by  a  fall  upon  cessa- 
tion of  work.  The  more  strenuous  the  work  and  the  less  trained 
the  man,  the  greater  and  the  earlier  will  be  the  fall.  This  may 
result  from  cardiac  weakness  or  may  be  a  result  of  Nature's  safe- 
guard against  cardiac  overstrain,  the  fall  of  pressure  being  brought 
about  reflexly  through  the  agency  of  the  depressor  nerve.  During 
youth  both  pulse  and  blood-pressure  are  more  labile  during  exer- 
cise and  tend  to  keep  pace  with  each  other.    In  adults  there  is  less 

1  Barach,  Joseph  H.,  and  Marks,  W.  L. :  Effect  of  Change  of  Posture  without 
Muscular  Exertion  on  the  Arterial  and  Venous  Pressures,  Arch.  Int.  Med.,  May 
15,  1913,  ii.  No.  5. 

'Stephens,  O.  Z.:  Blood-pressure  and  Pulse  Rate,  Jour.  Am.  Med.  .\ssn.,  1904, 
xliii,  955. 


156      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

tendency  for  the  pulse  and  more  for  the  pressure  to  rise.  In  health 
both  pulse  and  pressure  return  promptly  to  the  normal  upon  the 
cessation  of  work.  With  a  diseased  cardiovascular  system  this  is 
not  so  promptly  accomplished.  The  heart  which  has  been  weak- 
ened by  infectious  processes  shows  a  wide  range  and  a  prolonged 
duration  of  pulse  and  blood-pressure  variations.  The  amount  of 
psychic  effort  required  is  of  the  greatest  importance.  Work  which 
is  performed  passively,  automatically,  without  any  particular 
psychic  concentration,  is  not  accompanied  by  a  rise  in  tension. 
The  primary  fall  of  pressure  which  occurs  under  training  is  largely 
the  result  of  eliminating  the  volitional  psychic  factor.  An  increase 
of  pressure  under  muscular  work  depends  more  on  the  cerebral 
stimuli  required  than  on  the  amount  of  work  done.  In  the  hyp- 
notized subject,  imaginary  work  produced  an  elevation  of  pressure 
to  200  mm.  Hg.  (Klemperer).  These  causes  explain  many  of  the 
failures  of  testing  functional  capacity  by  measured  amounts  of 
work.  Although  we  can  measure  the  work  performed  in  kilogram- 
meters  we  have  no  means  of  estimating  the  amount  of  nervous 
force  and  psychic  energy  which  may  be  expended  upon  the  same 
task  by  different  classes  of  trained  and  untrained,  nervous  and 
phlegmatic,  energetic  and  lazy  individuals  (see  p.  384). 

The  increase  of  pressure  which  is  associated  with  muscular  effort 
affects  chiefly  the  systolic  pressure;  the  diastolic  element  tends  to 
lag  behind,  thus  increasing  the  amplitude  of  the  pulse.  On  assum- 
ing the  erect  posture  the  minute  volume  decreases  slightly,  the 
systolic  output  greatly  (20  per  cent.).  In  the  recumbent  posture 
the  minute  volume  in  women  increases  17.2  per  cent.,  and  the 
systolic  output  31  per  cent.  In  men  this  change  was  not  observed 
owing  probably  to  a  more  efficient  vasomotor  system.^  Lowsley^ 
found  that  physical  activity  caused  a  rapid  rise  in  blood-pressure 
which  precedes  the  increase  of  the  pulse  rate.  During  continued 
exercise  these  curves  show  but  little  change.  After  cessation  from 
work  the  fall  in  the  systolic  pressure  again  precedes  the  decrease  in 
the  pulse  rate.  A  secondary  rise  of  the  pulse  rate  occurs  which  is  a 
"reflex  effect  due  to  low  blood-pressure  of  the  subnormal  stage." 

Mwicidar  effort  sufficient  to  increase  the  pulse  rate  provokes  a  rise 
of  the  systolic,  diabolic  and  the  vemms  pressures.  Inasmuch  as  the 
systolic  pressure  rises  more  than  the  diastolic,  the  pulse-pressure 
is  increased. 

1  Lindhard,  J.:  Effect  of  Posture  on  the  Output  of  the  Heart,  Skand.  Arch.  f. 
Physiol.,  1913,  xxx,  395. 

*  The  Effects  of  Various  Forms  of  Exercise  on  SystoHc,  Diastolic,  and  Pulse  Pres- 
sures and  the  Pulse  Riite,  Am.  Jour.  Physiol.,  1911,  xxvii,  446. 


GRAUPNER'S  TEST  167 

Following  the  primary  maximal  rise  of  systolic  pressure  a  gradual 
decline  occurs,  but  while  exercise  is  being  continued  the  pressure 
never  reaches  the  normal  level.  The  diastolic  pressure  generally 
follows  the  systolic  curve  but  its  maximum  is  reached  later  and 
upon  cessation  from  work  it  invariably  falls  below  its  normal  level. 
According  to  Lowslfey  the  longer  the  subnormal  diastolic  phase, 
the  greater  the  circulatory  fatigue.  The  venous  pressure  shows 
often  a  sudden  drop  to  normal  after  cessation  from  exercise.  Exer- 
cise associated  with  strain  requiring  a  closed  glottis  and  a  rigid  chest, 
disproportionately  increases  blood-pressure  in  relation  to  the  pulse 
rate  and  very  markedly  increases  venous  pressure. 

The  Auscultatory  Phase  Test. — Goodman  and  Howell  suggested 
that  by  recording  the  relative  length  of  the  five  auscultatory  phases 
certain  deductions  regarding  myocardial  efficiency  could  be  drawn. 
They  group  the  second  and  third  phases  as  factors  of  cardiac 
strength  (C.  S.)  and  the  first  and  fifth  phases  as  factors  of  cardiac 
weakness  (C.  W.),  e.  g.,  in  a  given  case  w^ith  a  pulse-pressure  of 
45,  the  first  phase  constituted  31.1,  the  second  44.4,  the  third  11.1, 
the  fourth  13.3  per  cent,  of  the  total.    Therefore, 

C.  S.  :  C.  W.  : :  55.5  :  44.4. 

Swan,^  who  has  employed  this  method  in  72  cases  believes  it  is 
capable  of  yielding  useful  information  regarding  myocardial  strength 
at  the  time  the  observation  is  made. 

A  second  phase  which  forms  more  than  40  per  cent,  of  the  pulse- 
pressure,  and  a  C.  S.  :  C.  W.  ratio  in  which  the  former  is  greater 
than  the  latter,  bespeaks  a  competent  myocardium.  When  com- 
pensation is  deficient  the  C.  S.  — C.  W.  ratio  often  cannot  be  studied, 
owing  to  an  absence  of  one  or  more  phases.  When  this  is  the  case 
the  length  of  the  second  phase  may  be  taken  as  a  criterion  of  effi- 
ciency.   "A  long  second  phase  indicates  a  good  heart  muscle." 

Graupner's  Test. — Graupner-  endeavored  to  test  cardiac  func- 
tionation  by  noting  the  effects  of  measured  work  upon  the  pulse, 
the  blood-pressure  and  the  size  of  the  heart,  the  blood-pressure 
being  measured  with  a  Gartner  tonometer  and  taken  when  the 
pulse  had  reached  the  same  rate,  after  the  exercise,  which  it  had 
before  this  was  commenced.  His  investigations  led  him  to  the  fol- 
lowing conclusions:  (1)  Blood-pressure  remains  constant — cardiac 
sufficiency.      (2)   Blood-pressure  falls — cardiac  insufficiency.      (3) 

1  The  Auscultatory  Method  of  Blood-pressure  Determination,  A  Clinical  Study, 
Intemat.  Climes,  IV,  Series  24. 

2  Graupner:  Die  Mechanische  Priifung  und  Beurtheilung  der  Herzleistung, 
Berliner  Klin.,  1902.  xv.  No.  174;  Deutsch.  med.  Wchnschr.,  1906,  xxxii,  1029. 


158      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

Blood-pressure  rises,  but  returns  to  normal — compensatory  capac- 
ity. (4)  Blood-pressure  rises,  falls  rapidly,  without  a  tendency  to 
rise  again — fatigue. 

Barringer's  Test. — More  recently  Barringer^  has  studied  the  effect 
of  measured  exercise  upon  the  pulse  rate  and  the  blood-pressure. 
The  exercise  consisted  either  in  lifting  dumb-bells  or  in  riding  a 
bicycle  ergometer  of  the  Krogh  and  Linhard^  type.  He  found  that 
the  functional  capacity  of  the  heart  may  be  judged  by  the  form  of 
the  systolic  blood-pressure  curve  ajter  the  completion  of  the 
work. 

Ordinarily  as  a  result  of  active  exercise  the  pulse  rate  increases 
and  blood-pressure  rises  in  proportion  to  the  work  performed. 
Upon  cessation  of  work  both  pulse  and  pressure  return  to  the  normal. 
"  If  the  systolic  blood-pressure  reaches  its  greatest  height  not  imme- 
diately after  work  but  from  thirty  to  one  hundred  and  twenty 
seconds  later,  or  if  the  pressure  immediately  after  work  is  lower  than 
the  original  level,  that  work,  whatever  its  amount,  has  overtaxed 
the  heart's  functional  capacity,  and  may  be  taken  as  an  accurate 
measure  of  the  heart's  efficiency."  This  delayed  rise  of  systolic 
pressure  does  not  as  a  rule  vary  with  the  muscle  groups  employed 
(arms  or  legs).  Barringer  explains  the  foregoing  phenomena  by  the 
following  physiological  facts:  Muscular  work  increases  the  carbon 
dioxide  in  the  blood;  this  stimulates  the  nerve  centres  controlling 
the  suprarenal  glands  and  hence  an  increased  adrenalin  em  ia  results 
which  constricts  the  splanchnic  vessels  and  raises  blood-pressure. 
The  latter  is  abetted  by  the  increased  cardiac  rate.  After  exercise 
the  carbon  dioxide  diminishes  and  normal  values  are  reestablished.^ 
In  other  words,  with  an  individual  at  rest,  the  heart  only  discharges 
one-half  of  its  ventricular  content  with  each  systole,  but  under 
the  stimulus  of  exercise  and  when  more  blood  is  brought  to  it  from 
the  muscles  the  entire  ventricular  content  is  promptly  expelled 
and  hence  the  heart  becomes  smaller.  In  normal  individuals  hard 
work  rapidly  increases  the  systolic  pressure  as  a  result  of  which  the 
ventricle,  when  fatigue  occurs,  fails  to  completely  discharge  its 
content.  Upon  cessation  from  work  the  splanchnic  vessels  relax 
and  blood-pressure  falls,  hence  the  ventricle  again  begins  to  empty 
itself  completely.    This  increased  output  overshadows  the  splanch- 

>  Barringer,  T.  B.,  Jr.:  The  Circulatory  Reaction  to  Graduated  Work  as  a  Test 
of  the  Heart's  Functional  Capacity,  Arch.  Int.  Med.,  March,  1916,  xvii,  363. 

2  Skand.  Arch.  f.  Physiol.,  1913,  xxx,  378. 

3  Cannon:  Am.  .Jour.  Physiol.,  1914,  xxxiii,  356.  Von  Anrep:  Joun  Physiol.,  1913, 
xlv,  318.  Hooker:  Am.  Jour.  Physiol.,  1911,  xxviii,  235.  Schneider  and  Havens: 
Ibid.,  1915,  xxxvi,  239. 


BARRINGER'S  TEST  159 

nic  dilatation  and  hence  pressure  temporarily  rises,  thus  explaining 
the  delayed  rise  in  blood-pressure. 

In  patients  with  cardiac  disease  the  systolic  rise  during  exercise 
is  slight  and  the  fall  of  pressure  often  begins  during  the  period  of 
work.  The  curve  after  work  is  similar  to  that  occurring  in  normal 
subjects  but  much  less  muscular  work  is  sufficient  to  develop  the 
delayed  rise. 

Method  of  Performing  Barringer's  Test  of  the  Heart's  Functional 
Capacity. — "The  apparatus  used  consists  of  pairs  of  5-,  10-,  15-  and 
20-pound  dumb-bells,  and  a  steel  bar  about  40  inches  long  weighing 
25  pounds.  Two  types  of  movements  are  done  with  the  bells.  In 
the  first  a  pair  of  dumb-bells  is  held  at  the  shoulders,  one  in  each 
hand,  and  then  pushed  alternately  above  the  head  and  toward  the 
median  line  until  the  arms  are  fully  extended.  As  one  bell  moves 
up  fairly  rapidly  the  other  bell  returns  to  the  shoulder,  the  two 
moving  in  a  sort  of  see-saw  rhythm.  In  the  other  movement  a  bell 
is  held  in  each  hand,  the  arms  hanging  by  the  side  of  and  close  to 
the  body,  and  then  each  forearm  is  alternately  flexed,  raising  the  bell 
to  the  shoulder.  The  patient  stands  or  sits  according  to  his  con- 
dition. But  one  movement  is  performed  with  the  steel  bar.  It  is 
picked  up  from  the  floor  with  both  hands,  raised  first  to  a  level  with 
the  shoulders,  then  pushed  above  the  head  until  the  arms  are  fully 
extended  and  then  quickly  lowered  to  the  floor  again  with  a  single 
rapid  motion. 

"It  is  possible  to  calculate  approximately  the  number  of  foot- 
pounds of  work  performed  in  each  of  these  movements.  There  is 
a  certain  amount  of  work,  however,  which  we  cannot  estimate  in 
foot-pounds.  When  a  patient  stands  with  a  pair  of  dumb-bells  at 
his  shoulders  without  moving  them,  work  is  done  as  shown  by  his 
circulatory  reactions,  but  we  cannot  estimate  it  in  foot-pounds. 
This  unknown  factor  can  be  ignored,  however,  for  our  purpose. 

"Most  adults  average  2  feet  as  the  distance  through  which  a 
bell  is  pushed  from  the  shoulder  to  full  extension  of  the  arm.  In 
the  flexion  movement,  the  distance  through  which  the  bell  is  car- 
ried from  the  side  of  the  body  to  the  shoulder  averages  from  2  feet 
to  2  feet  6  inches.  Now  if  a  5-pound  bell  is  pushed  through  2  feet, 
10  foot-pounds  of  work  are  done.  If  the  total  number  of  pushes 
are  twenty,  200  foot-pounds  are  done.  For  the  sake  of  comparison, 
the  time  it  takes  a  patient  to  do  any  quantity  of  work  should  be 
noted. 

"  If  the  patient  whose  heart  is  to  be  tested  has  but  recently  recov- 
ered from  an  attack  of  cardiac  insufficiency,  it  is  well  to  start  with 


160      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

a  pair  of  5-pound  bells,  the  patient  sitting  on  a  stool.      Two  hun 
dred  foot-pounds  of  work  are  then  given  either  by  flexing  or  extend- 
ing the  bells.    The  pulse  rate  and  blood-pres3ure  are  taken  every 
thirty  seconds, 

"After  the  pressure  and  pulse  have  returned  to  the  original,  300 
or  400  foot-pounds  are  done  in  the  same  way.  The  work  is  increased 
with  each  experiment  until  we  reach  a  delayed  rise  in  blood-pressure. 
The  experiment  which  has  caused  a  delayed  rise  should  always  he 
repeated  after  a  few  minutes'  rest,  with  a  slightly  increased  amount 
of  work,  for  the  purpose  of  confirmation.  When  once  the  amount  of 
work  which  will  produce  a  distinct  delayed  rise  in  blood-pressure 
is  ascertained,  it  is  quite  remarkable  how  little  the  results  vary 
on  a  repetition  of  the  experiment  with  the  same  or  increased  work. 
Yet  if  our  test  is  valid  this  should  be  so. 

"The  following  examples  illustrate  this  point: 

"This  patient  was  sixty-four  years  old  and  suffered  from  aortic 
regurgitation  and  cardiac  insufficiency. 


Time 
3.45 

3.45    . 

160  foot-pounds 

(10-pound  bel 

Pulse  rate                Systolic  I 

76 
1  extended  eight  times) 

.     80 

.     88 

.     80 

.     80 

.     80 

.     80 

.     80 

.     80 

.     80 

'11  extended  ten  times) 
.     88 

.     84     Delayed  rise       i 
.     80 
.     76 
.     76 
.     80 
.     80 

extended  twelve  times) 
.     88 
.     84 

^     Delayed  rise 

'.     80 
.     76 
.     80 
.     76 
.     76 
.     76 

)lood-pressurc 
132 

132 

3.46    . 

138 

3.46^ 
3.47    . 

134 
134 

3.47^ 
3.48    . 

132 

134 

3.49    . 

134 

3.49    . 

134 

3.55    . 

130 

3.56    . 

200  foot-pounds 

3  (10-pound  be 

fl42 

3.56? 

146 

3.57    . 

142 

3.57? 

122 

3.58    . 

136 

3.59    . 

132 

4.03    . 

130 

4.04    . 

240  foot-pounds  (10-pound  bell 

fl36 

4.045 

142 

4.05    . 

138 

4.055 

144 

4.06    . 

144 

4.06^ 
4.07    . 

,138 

144 

4.08    . 

134 

4.09    . 

128 

4.13    . 

130 

"As  a  general  rule  a  patient's  cardiac  capacity  will  vary  but  slightly 
from  day  to  day.    If  he  improves  in  general  condition  his  cardiac 


KATZENSTEIN'S  TEST 


161 


capacity  increases,  and  if  he  retrogrades  it  decreases.  Lack  of  sleep 
or  transient  infections  have  very  prompt  and  decided  effects  on  the 
cardiac  capacity,  particularly  in  persons  who  already  have  damaged 
hearts. 

"Patients  showing  a  delayed  rise  of  pressure  with  work  amount- 
ing to  less  than  100  foot-pounds  per  minute,  usually  present  other 
signs  of  cardiac  insufficiency.  An  exception  to  this  statement  occurs 
in  aged  subjects.  Capacities  ranging  between  100  and  1000  foot- 
pounds are  met  with  in  patients  who  can  walk  short  distances. 
Tests  of  less  than  1000  foot-pounds  per  minute  may  be  construed 
as  confirmatory  of  a  myocardial  lesion."^ 


120 

d 

no                    / 

X 

If 

100                           '/ 

v^ 

e 

/  / 
90                     /  / 

/  / 

80      ,sy 

Cx, 

0 

a 

b 

Fig.  69. — The  absolute  sphygmogram.  If  the  cuff  pressure  be  raised  to  100  mm. 
Hg.  only  that  part  of  the  pulse  wave  which  is  in  excess  of  this  pressure  will  be  traced 
(see  page  163). 

Katzenstein's  Test. — This  test  for  determining  the  degree  of  func- 
tional capacity  of  the  heart  is  based  upon  the  manner  in  which  this 
organ  responds  to  compression  of  both  iliac  arteries.- 

Experimentally  in  animals,  if  some  of  the  large  vessels  are  oblit- 
erated, blood-pressure  rises  while  the  pulse  rate  remains  stationary. 


'  Barringer,  T.  B.:     Studies  of  the  Heart's  Functional  Capacity  as  Estimated  by 
the  Circulatory  Reaction  to  Graduated  Work,  Arch.  Int.  Med.,  1916,  xvii,  670. 
2  Katzenstein:  Berliner  klin.  Wchnschr.,  1907,  xliv.  No.  16. 
U 


162      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

In  human  beings  it  was  found  that  if  the  heart  was  functionally 
potent,  bilateral  obliteration  of  the  iliac  arteries,  maintained  for 
from  two  to  five  minutes,  caused  a  rise  in  blood-pressure  of  from 
5  to  15  mm.  of  mercury;  the  pulse  rate  remained  stationary  or 
even  diminished.  In  the  case  of  an  hypertrophied  heart,  with 
good  compensation,  the  blood-pressure  rises  perhaps  to  40  mm., 
the  rate  being  still  unaffected.  If  there  is  slight  insufficiency,  the 
pressure  does  not  rise,  whereas  the  pulse  does  become  accelerated. 
In  severe  insufficiency  the  pressure  falls  and  the  pulse  becomes 
more  rapid.  These  tests  are  made  with  the  subject  in  the  recumbent 
posture.  The  sources  of  error  in  this  method  are  manifestly  mental 
excitement,  and  the  possibility  of  producing  pain  during  the  com- 
pression of  the  arteries,  either  of  which  might  seriously  militate 
against  the  accuracy  of  the  results;  but  with  due  care  both  of  these 
factors  may  be  eliminated. 

With  a  view  toward  investigating  Kat^enstein's  test,  the  author^ 
studied  a  number  of  cases  both  among  healthy  individuals  and 
among  those  in  whom  cardiac  weakness  or  disease  was  assured. 
As  the  result  of  these  investigations  it  was  found  that,  generally 
speaking,  the  cases  responded  to  the  test  as  has  been  contended 
by  the  deviser  of  it.  There  were,  however,  notable  exceptions  in  a 
number  of  instances.  Although  the  majority  of  cases  with  manifest 
cardiac  weakness  responded  positively  to  the  test,  yet — and  here 
lies  the  main  ground  for  objection — many  of  them  did  so  in  such 
equivocal  terms,  that  is,  by  such  small  changes  in  the  pulse  rate  or 
blood-pressure,  that  the  final  decision  was  left  largely  to  the  per- 
sonal equation  of  the  observer.  Morelli-  suggests  that  compres- 
sion be  exercised  by  means  of  inflated  rubber  stockings.  In  a 
recent  communication  based  upon  three  thousand  cases,  during 
the  last  ten  years,  Katzenstein^  reiterates  his  belief  in  the  efficacy 
of  his  test.  He  has  found  it  of  especial  value  in  discovering  cardiac 
weakness  in  operative  cases  in  which  chloroform  was  subsequently 
used  as  an  anesthetic. 

This  test  has  been  investigated  by  numerous  writers.  It  may  at 
times  have  some  corroborative  value,  but  much  dependence  should 
not  be  placed  upon  it.  A  test  based  on  the  same  general  principle 
has  been  suggested  by  Mosler,^  who  estimates  the  blood-pressure 

'  Norris,  G.  W. :  The  Functional  Capacity  of  the  Heart,  Internat.  Clinics,  vol.  i, 
Series  17. 

'  Delia  Capacita  Funzionale  del  ouore  e  dei  Vasi  Sanguini,  Bull.  Sac.  Med.  Chir. 
di  Pa\na,  March  12,  1910. 

*  Duetsch.  med.  Wchnschr.,  1915,  vol.  xli.  No.  16. 

<  Der  Atemstillstand  in  tiefer  InspiratioiisstelluuK:  Ein  Ver.such  z.  Borutcilung 
der  KreislaufFunktion,  Ztschr.  f.  klin.  Med.,  1913,  Ixxviii,  133. 


THE  VENOUS  PRESSURE  TEST 


163 


after  a  deep  forced  inspiration  at  the  conclusion  of  which  the  breath 
is  held. 

The  Venous  Pressure  Test  (Schott's^  Test). — It  appears  that  in 
health  if  the  patient  raises  his  arm  to  an  angle  of  60  degrees  while 
lying  quietly  without  any  other  muscular  effort,  the  venous  pressure 
shows  on  an  average  an  increased  pressure  of  0.5  cm.  H2O  (some- 
times no  increase,  or  even  a  fall).     In  well-compensated  heart 


Fig.  70. — Absolute  sphygmograms  and  pulse  tracings  from  a  case  of  marked 
hypertension  and  from  a  case  of  marked  hypotension.  Showing  that  the  pulse 
tracing  gives  a  very  inaccurate  representation  of  the  actual  height  of  the  arterial 
pressure.     (After  Gallavardin.) 

lesions  the  increased  pressure  averages  2.3  cm.;  in  broken  compen- 
sation, 4  to  7  cm.;  in  conditions  of  anasarca,  etc.,  7.3  cm.  He  there- 
fore considers  figures  above  3  cm.  as  pathological.  Passive  eleva- 
tion of  the  limb  produces  no  increase  of  venous  pressure. 


'Die  Erhohung  des  Druckes  in  venosen  System  bei  Anstrengimg  als  Mass  fiir 
die  Funktionstuchtigkeit  des  menschlichen  Herzens,  Deutsch.  Arch,  f.  klin.  Med., 
1912,  cviii,  537-553. 


164      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

The  Absolute  Sphygmogram. — The  information  obtainable  from 
the  pulse  tracing  alone,  so  far  as  blood-pressure  is  concerned,  is 
slight  because:  (1)  we  do  not  know  the  actual  value  of  the  abscissa 
and  (2)  because  the  actual  length  of  the  waves  depends  largely  on 
the  adjustment  of  the  sphygmograph  (amount  of  pressure  exerted 
on  the  underlying  artery). 


210 

MX 

200 

\ 

I'.K) 

s 

L 

180 

— 

\ 

170 
100 

N 

i 

. 

150 

rr 

140 

!    \ 

ia)j 
120 

■  ■  \ 

k 

\ 

s 

no 

i    .' 

s 

MN 

110 

lOo 

ill 

r 

k 

. 

90 

/ 

s 

s 

80 

/ 

;     !    " 

k 

70 

"^ 

k 

60 

JT 

00 

^. 

SO 

1 

^ 

40 

30 

20 

10 

0 

0 

1 

Fig.  71. — Absolute  sphygmogram  and  pulse  tracing  from  a  case  of  hypertension 
and  from  a  case  of  hypotension.     (After  Gallavardin.) 


In  1904  Sahli  suggested  a  method  for  plotting  the  sphygmogram 
in  absolute  pressure  values.  His  method  depends  upon  the  fact 
thst  if  sphygmograms  are  taken  from  the  radial  artery  while  a 
blood-pressure  cuff  is  applied  to  the  brachial  artery  above  with 
increasing  pressures,  the  sphygmogram  will  be  traced  of  only  that 
portion  of  the  pulse  curve  corresponding  to  intra-arterial  pressures 
higher  than  the  pressure  in  the  cuff.  Thus,  if  Fig.  69  represents 
the  actual  pressure  curv^e  of  the  pulse  in  the  artery,  if  the  pressure 
in  the  cuff  be  raised  to  100  only  that  portion  of  the  pulse  curve 
drawn  heavy  and  corresponding  to  pressures  above  100  will  be 
traced.     It  is  therefore  possible,  by  altering  the  pressures  in  the 


THE  BLOOD-PRESSURE  QUOTIENT 


165 


cuff  and  noting  the  amount  of  the  sphygmogram  traced  at  each 
pressure,  to  determine  the  absolute  pressure  of  any  point  on  the 
pulse  curve. 

The  time  relations  of  these  points  may  be  determined  from  the 
sphygmogram.  The  curve  may  then  be  plotted  on  cross-section 
paper,  allowing  the  vertical  lines  to  represent  time  units  and  the 
horizontal  lines  units  of  blood-pressure.  It  is  only  from  such  a 
curve  that  the  true  mean  pressure  can  be  determined.  Thus,  if 
the  length  of  a  sufficient  number  of  equally  spaced  vertical  lines 


Fig.  72. — Show-ing  absolute  sphygmogram  and  pulse  tracing  from  a  subject  with 
normal  blood-pressure,  and  that  of  a  case  of  nephritic  hypertension.  (After  Galla- 
vardin.) 


from  the  base  line  a-b  to  the  pressure  curve  c,  d,  e,  f,  g,  be  measured 
and  their  average  taken,  such  average  will  be  the  true  mean  pressure. 
For  clinical  purposes  Sahli  constructs  a  simplified  form  by  plotting 
only  the  systolic  pressure  or  crest  of  the  pulse  curve  (d),  and  the 
diastolic  pressure  or  lowest  point  of  the  pulse  curve  (c  and  g),  thus 
obtaining  the  dotted  figure  a,  c,  d,  g,  h.  From  such  a  diagram  one 
can  judge  accurately  as  to  the  quickness  or  slowness  of  the  pulse 
(pulsus  celer,  or  pulsus  tardus). 

The    Blood-pressure    Quotient.— Let    us    assume    that    the    data 
obtained   regarding  systolic  and   diastolic  pressures  are   correct. 


166      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

What  conclusions  are  we  warranted  in  drawing  regarding  the 
amount  of  work  performed  by  the  heart  and  the  amount  of  its 
systolic  output?  The  question  has  recently  been  ably  summarized 
by  O.  Miiller/  from  whose  article  I  have  freely  drawn. 

Tigerstedt  has  shown  that  the  pulse-pressure  divided  hy  the  systolic 
pressure  is  of  value  in  estimating  the  part  played  by  vascular 
resistance  and  cardiac  work  respectively  in  changing  circulatory 
conditions. 

The  rationale  of  the  method  is  as  follows :  With  increased  cardiac 
work,  the  pulse-pressure  as  well  as  the  systolic  pressure  increases. 
If,  on  the  other  hand,  peripheral  tonus  alone  increases,  the  systolic 
pressure  rises,  while  the  pulse-pressure  falls.  Vasodilatation  pro- 
duces a  fall  of  systolic  pressure  and  an  increase  of  pulse-pressure. 
Therefore  if  the  systolic  pressure  and  the  pulse-pressure  move  in 
the  same  direction  and  proportionately,  the  cause  lies  in  the  heart; 
if  in  the  reverse  direction,  or  not  proportionately,  the  cause  lies  at 
least  partly  in  changes  in  vascular  tonus.  The  cardiac  element  is 
also  indicated  by  the  number  of  systoles. 

_   „    _  Pulse-pressure  .  ,,       u     t.  n  o\ 

B.  P.  Q.  =  -^ — r-p =  (normally  about  0.3) 

Systolic  pressure 

1.  A  changed  systolic  pressure  while  the  quotient  remains  the 
same  points  to  a  change  in  the  work  of  the  heart.  If  both  systolic 
and  pulse-pressure  rise,  an  increased ;  and  if  both  fall,  a  diminished 
cardiac  activity  may  be  assumed. 

2.  When  systolic  pressure  and  blood-pressure  quotient  move  in 
approximately  equal  but  opposite  directions,  indications  point  to 
an  alteration  of  vascular  tone.  Thus  an  increase  in  systolic  pressure 
with  a  fall  of  quotient  =  increased  tonus  and  vice  versa. 

3.  When  systolic  pressure  and  quotient  move  unequally  in  the 
same  or  in  opposite  directions,  both  the  heart  and  the  vascular  sys- 
tem contribute  to  the  effect.  With  the  limitations  imposed  by  the 
response  of  the  pulse-pressure  to  factors  other  than  the  systolic 
output  (already  considered  on  page  53),  and  if  our  estimation  of  the 
systolic  and  diastolic  pressures  be  accurate,  these  assumptions  are 
warranted.  The  variations  of  aortic  elasticity  for  different  degrees 
of  pressure  are  clinically  a  negligible  quantity.  But  a  far  more 
serious  source  of  error  lies  in  the  fact  that  the  smaller  arteries  and 
arterioles  possess  a  distinct  tonus,  the  amount  of  which  we  are  as 
yet  unable  to  measure.    If  the  arterial  system  merely  consisted 

1  Die  unblutige  Blutdruckmessung  u.  ihre  Bedeutung  f.  d.  prakt.  Med.,  Med. 
Klinik,  January  12,  1908,  p.  47  et  seq. 


THE  BLOOD-PRESSURE  QUOTIENT  167 

of  rubber  tubing  our  figures  would  certainly  be  at  least  approxi- 
mately correct,  and  our  deductions  correspondingly  accurate;  in 
illustration  of  this  it  has  been  demonstrated  that  in  cases  of  arterio- 
sclerosis the  pulse-pressure  is  often  twice  as  large  as  in  a  normal 
individual,  but  we  have  no  right  to  conclude  from  this  that  in 
such  a  case  the  systolic  output  is  correspondingly  great.  It  is  far 
more  likely  in  such  an  instance  that  the  difference  is  due  to  the 
rigidity  of  the  arterial  wall.  The  pulsatory  reaction  of  a  contracted 
artery  is  entirely  different  from  that  of  a  relaxed,  artery  of  the  same 
caliber.  Again,  as  F.  Klemperer  has  shown,  if  we  dip  one  arm  into 
hot  and  the  other  into  cold  water,  the  pulse-pressure  will  be  found 
to  decrease  in  the  former  and  to  increase  in  the  latter;  and  yet  we 
know  that  cold  produces  vascular  contraction.  Which  of  the  two 
sides  shall  we  choose  as  the  index  of  systolic  cardiac  output? 

It  may  be  argued  in  reply  that  such  extremes  as  the  hot-  and 
cold-water  experiment  do  not  occur  under  normal  conditions,  but 
notwithstanding  we  must  bear  in  mind  the  fact  that  plethysmo- 
graphic  studies  have  indubitably  demonstrated  the  fact  that  fre- 
quent and  often  extensive  vasomotor  changes  are  going  on  more 
or  less  constantly  in  the  normal  human  economy,  especially  as  the 
result  of  pain,  psychic  influence  or  temperature  change,  all  of  which 
are  apt  to  enter  into  an  ordinary  blood-pressure  estimation. 

■Fuerst  and  Soetbeer^  suggest  that  the  Strassburger  formula  be 
modified  to  read : 

Pulse-pressure 

Diastolic  pressure  +  5  pulse-pressure 

believing  that  the  pressure  variations  in  the  aorta  are  thus  more 
nearly  portrayed. 

Applying  a  table  originally  devised  by  Beanus,  Erlanger  and 
Hooker  indicate  the  deductions  to  be  drawn  as  to  cardiac  activity 
and  vascular  resistance  from  blood-pressure,  pulse-pressure,  and  car- 
diac rate  as  follows.  Since  the  mean  pressure  follows  the  diastolic 
more  closely  than  the  systolic  they  recommend  the  former  as  the 
ndicator  of  blood-pressure  in  the  table. 


Determinable  factors. 

Causative 

factors. 

Diastolic 

Pulse-pressure  X  pulse  rate 
(velocity  of  flow). 

Energy  from 

Peripheral 

pressure. 

heart. 

resistance. 

Constant 

/  Increased 

Increased 

Diminished 

\  Diminished 

Diminished 

Increased 

j  Unchanged 

Increased 

Increased 

Increased    . 

•    I  Increased 

Increased 

Unchanged 

!  Diminished 
1  Unchanged 

Unchanged 

Increased 

Diminished 

Diminished 

Diminished 

{  Increased 

Unchanged 

Diminished 

[  Diminished 

Dimini.shed 

Unchanged 

'  Untersuchungpn  u.  d.  Beziehungen  zw.  Fuellung  u.  Druck.  in  d.  .\orta,  Deutsch. 
Arch.  f.  klin.  Med.,  1907,  vol.  xc. 


168      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

The  tal)le,  however,  is  too  diagrammatic  to  be  of  value  except 
as  an  illustration  of  the  general  principles  involved.  For  example, 
cases  of  nephritic  hypertension  with  increased  peripheral  resistance 
and  a  compensatory  increase  of  cardiac  activity  show  commonly  an 
increase  both  of  diastolic  pressure  and  of  pulse-pressure  X  pulse 
rate.  The  table  would  interpret  such  an  effect  upon  the  blood- 
pressure,  pulse-pressure  and  pulse  rate  as  indicating  increased  car- 
diac activity,  but  unchanged  peripheral  resistance — an  entirely 
erroneous  interpretation.  This  limitation  in  the  table  is  of  course 
due  to  the  fact  that  it  deals  with  changes  in  the  various  factors 
only  as  to  the  direction  of  the  change  (whether  increased  or  dimin- 
ished), and  not  as  to  the  degree  of  the  change. 

Velden  found  that  if  the  two  foregoing  formulas — Strassburger's 
and  that  of  Erlanger  and  Hooker — were  applied  to  the  same  case 
they  often  led  to  diametrically  opposite  conclusions. 

The  Energy  Index. — Barach^  found  that  what  he  terms  the  energy 
index  (S.  D.  II.  Index)  is  useful  as  a  clinical  estimation  of  the 
amount  of  cardiovascular  energy  expended,  e.  g.: 

Blood-pressure.  Pulse  rate.  I  ndex. 
Systolic  pressure  .  .  120  mm.  Hg.  X  72  =  8.640 
Diastolic  pressure    .      .      70     "       "X       72    =       5.040 

Energy  index    (sum   of  

above)        ....     190     "       "X       72    =  13.680  mm.  Hg.  per  min. 

The  highest  energy  index  in  normal  cases  is  about  20,000  mm. 
Hg.  per  minute.  In  pathological  cases  figures  as  high  as  50,000  were 
encountered.  A  considerable  number  of  the  cases  with  high  indices 
died  of  apoplexy. 

The  Amplitude-frequency  Product. — Yon  Recklinghausen^  ap- 
proaches the  question  from  a  different  direction,  yet  reaches  con- 
clusions somewhat  similar  to  those  of  Strassburger.  For  him  the 
vascular  system  consists  of  two  reservoirs;  the  smaller  pulsating 
(arterial)  and  the  larger  continuously  flowing  (venous).  The  circu- 
lation between  the  two  by  means  of  the  capillaries  is  not  directly 
aflected  by  cardiac  activity.  He  assumes  that  to  a  certain  extent 
at  least  the  diastolic  blood  flow  occurs  as  in  a  series  of  stand-pipes, 
according  to  Poiseuille's  law.  He  believes  that  to  a  certain  degree 
the  tliastolic  limb  of  the  pulse  wave  can  be  shown  to  be  identical 
with  an  ordinary  outflow  curve.     He  assumes  that  the  arteries 

'  The  Energy  Index,  Jour.  Am.  Med.  Assn.,  1914,  Ixii,  525. 

*  Was  vir  durch  d.  Pulsdruckkurve  u.  d.  Pulsdruckamplitude  iiber  d.  grossen 
Kroislauf  crfahren,  Arch.  f.  exp.  Path.  u.  Phar.,  1906,  vol.  Ivi. 


THE  AMPLITUDE-FREQUENCY  PRODUCT  169 

themselves  are  not  actively  concerned  in  the  propulsion  of  the 
blood  stream.^ 

Now,  if  we  register  the  pulse  wave  from  a  brachial  cuff  with  a 
tambour  manometer  at  a  certain  pressure,  we  shall  find  the  curve 
indicating  a  certain  relationship  between  the  amount  of  blood  pro- 
pelled in  a  given  time  and  the  elasticity  of  the  artery.  Since  it  is 
not  always  feasible  to  take  a  tracing  and  lay  off  an  absolute  sphyg- 
mogram,  he  suggests  as  a  practical  method  the  amplitude  (pulse- 
pressure)  multiplied  by  frequency  (pulse  rate)  =  second  volume 
-4-  arterial  dilatability;  in  other  words,  amplitude  multiplied  by 
rate  is  proportionate  to  systolic  output  divided  by  distensibility. 
Thus,  if  we  can  be  sure  that  distensibility  remains  unchanged,  then 
amplitude  is  a  relative  measure  of  systolic  output.  But  how  are 
we  to  gauge  this  factor  of  distensibility?  Von  Recklinghausen 
suggests  that  the  following  axioms  may  throw  some  light  on  the 
question : 

1.  With  a  constant  pressure  and  with  increasing  tonus  the  dis- 
tensibility of  the  artery  diminishes.  With  a  decrease  of  tonus,  it 
increases. 

2.  Increased  arterial  tension  generally  goes  hand-in-hand  with 
increased  vascular  tonus.  We  thus  in  all  probability  have  a  doubly 
decreased  distensibility. 

3.  In  sclerotic  arteries  the  relative  distensibility  of  bloodvessels 
is  diminished. 

We  must  not  use  the  rules  of  the  blood-pressure  quotient  too 
absolutely.  It  is  evident  that  we  can  draw  no  mathematically  rigid 
conclusions  from  changes  of  pulse-pressure  e\^en  in  the  same  indi- 
vidual, and  much  less  can  we  hope  to  use  the  data  thus  obtained 
in  comparison  with  other  individuals.  We  cannot  by  any  rule  con- 
vert millimeters  of  pulse-pressure  into  cubic  centimeters  of  systolic 
output.  It  has  been  shown  that  in  the  case  of  the  diseased  heart 
which  is  manifesting  fatigue,  the  amplitude-frequency  product 
increases  less  rapidly  than  in  health;  it  may  indeed  be  entirely  lack- 
ing. Tiedemann,  who  compared  the  amplitude  and  the  amplitude- 
frequency  product  in  healthy  and  diseased  hearts  after  the  lifting 
of  weights,  found  that  in  the  former  case  both  of  these  factors 
increased,  while  in  the  latter  they  did  so  to  a  lessened  extent  or  not 
at  all.  These  results  were  indubitable,  but  what  construction  should 
be  put  upon  them  was  less  clear.  Without  a  knowledge  of  the  state 
of  the  vascular  tonus  no  actual  figures  could  be  obtained. 

'  This  lielief  has  been  much  questioned  of  late,  based  on  the  observation  of  Greutz- 
ner  that  with  an  equal  amount  of  pressure  applied  to  an  artery,  more  blood  can  be 
forced  out  in  the  direction  of  normal  flow  than  in  the  opposite  direction. 


170      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

Discussion  of  the  Foregoing  Tests. — Although  not  enthusiastic 
over  the  amount  of  knowledge  to  be  derived  by  the  use  of  the  fore- 
going tests,  I  extensively  use  and  place  some  reliance  upon  the 
results  of  Cramptons  test. 

Grawpner  failed  to  measure  pressure  before  each  experiment, 
made  his  readings  too  infrequently  and  allowed  the  cuff  to  remain 
inflated  too  long.  This  test  requires  special  apparatus.  Barringer's 
modification  seems  to  be  a  distinct  improvement.  The  investiga- 
tions of  Swan^  which  concerned  themselves  with  Tigerstedt's,  Good- 
man and  Howell's,  Stone's,  and  the  postural  pulse  test,  led  him 
to  prefer  the  first-mentioned  two.  He  found  that  a  second  phase  of 
30  per  cent,  or  less  or  a  cardiac  efficiency  factor  of  40  per  cent, 
or  over  seems  to  indicate  myocardial  inefficiency. 


METHODS  OF  ESTIMATING  THE  RATE  OF  BLOOD  FLOW.^ 

While  a  knowledge  of  the  state  of  the  blood-pressure  is  often  of 
great  value,  it  gives  us  no  clue  as  to  the  rapidity  of  the  circulation 
— the  mass  movement  of  the  blood.  A  high  vascular  tension  may 
be  associated  with  a  small  blood  flow  and  vice  versa;  for  the  rapidity 
of  the  circulation  depends  not  only  upon  arterial  pressure  but  also 
upon  the  caliber  of  the  vessels  between  artery  and  vein,  and  under 
some  circumstances  upon  venous  pressure.  It  has  been  shown 
that  the  circulation  rate  increases  in  proportion  to  the  oxygen 
consumption  in  a  manner  corresponding  to  the  increase  in  total 
ventilation;  and  it  has  been  suggested  that  the  chief  controlling 
factor  of  the  circulation  rate  is  the  hydrogen  ion  concentration  of 
the  arterial  blood.^ 

G.  N.  Stewart*  has  devised  a  method  of  determining  the  rate  of 
Jlow  which  depends  on  the  fact  that  "  the  amount  of  heat  produced 
by  a  part  like  the  hand  during  rest  is  negligible  in  comparison  with 
the  heat  conveyed  to  it  by  the  arterial  blood.  If,  then,  we  deter- 
mine the  amount  of  heat  given  off  by  the  hand  to  a  calorimeter 
in  a  given  time,  and  know  the  temperature  of  the  incoming  (arterial) 

•  How  Shall  We  Tell  Whether  or  Not  the  Myocardium  is  Competent,  Arch.  Int. 
Med.,  1915,  XV,  269. 

^  See  page  37. 

'  Boothby,  Walter  M.:  A  Determination  of  the  Circulation  Rate  in  Man  at  Rest 
and  at  Work,  Am.  Jour.  Physiol.,  1915,  xxxvii,  383. 

*  Measurement  of  the  Rate  of  Flow  of  the  Blood  in  Man,  Cleveland  Med.  Jour., 
April,  1911,  X,  385;  Studies  on  the  Circulation  in  Man,  Heart,  October,  1911,  iii,  33. 


METHODS  OF  ESTIMATING  THE  RATE  OF  BLOOD  FLOW     171 

and  of  the  outgoing  (venous)  blood,  we  can  calculate  how  much 
blood  must  have  passed  through  the  hand  in  order  that  it  might 
give  off  this  amount  of  heat.  The  quantity  of  heat  given  off  is 
estimated  by  putting  the  hand  into  a  calorimeter. 

"It  consists  of  an  inner  copper  vessel  containing  a  known  amount 
of  water  (in  the  experiments  usually  about  three  liters),  into  which 
the  hand  is  inserted  through  an  orifice  of  appropriate  size  and  shape 
in  the  lid,  heat-tight  closure  being  made  by  the  collar  of  thick  felt 
on  the  top  of  the  calorimeter.  The  inner  vessel  is  packed  in  broken 
cork  in  a  larger  outer  vessel  and  the  lid  is  covered  with  sheet  cork 
to  reduce  so  far  as  possible  the  loss  of  heat,  and  to  protect  the 
calorimeter  against  irregular  cooling  when  exposed  to  draughts. 
The  actual  loss  is  estimated  by  separate  control  experiments,  and 
added  to  the  amount  of  heat  given  off  by  the  hand  as  indicated 
by  the  rise  of  temperature  in  the  water.  The  hand  is  prepared  for 
insertion  into  the  calorimeter  by  a  preliminary  immersion  for  not 
less  than  ten  minutes  in  a  large  bath  containing  water  at  approxi- 
mately the  same  temperature  as  that  in  the  calorimeter.  The 
temperature  of  the  water  in  the  calorimeter  is  read  on  a  thermom- 
eter permitting  hundredths  of  degrees  to  be  accurately  estimated. 
The  calorimeter  is  mounted  on  a  stand  which  can  be  raised  or  low- 
ered by  a  screw  to  permit  its  use  either  for  a  patient  sitting  in 
bed  or  for  an  ambulatory  patient  who  is  able  to  sit  in  a  high  chair. 
As  a  general  rule  the  flow  in  the  two  hands  is  simultaneously  meas- 
ured. The  quantity  of  blood  in  grams  flowing  through  the  hand 
in  the  time  of  the  experiment  is  given  by  the  formula: 

"Here  Q  is  the  quantity  of  blood,  //  the  heat  given  off  by  the 
hand,  T  the  temperature  of  the  arterial  blood,  T^  the  tempera- 
ture of  the  venous  blood,  and  s  the  specific  heat  of  blood.  In 
estimating  //  the  water  equivalent  of  the  hand  itself  (obtained 
by  multiplying  its  volume  by  0.8)  and  the  water  equivalent  of 
the  calorimeter  (80  grams)  must  be  added  to  the  quantity  of  heat 
corresponding  to  the  actually  observed  rise  of  temperature.  The 
specific  heat  of  blood  is  taken  at  0.9.  Knowing  the  volume  of 
the  hand,  we  can  express  the  flow  in  grams  per  minute  per  100 
c.c.  of  hand  substance.  The  volume  of  the  hand  is  easily  esti- 
mated by  the  amount  of  water  which  it  displaces  when  immersed 
in  a  glass  douche-can  to  the  level  to  which  it  was  inserted  in  the 


172      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

calorimeter.  The  douche-can  is  connected  by  the  tubulure  to  a 
burette,  on  the  scale  of  which  the  vertical  displacement  of  the 
water  is  read  off.  The  amount  of  water  which  must  be  added  to 
that  in  the  can  in  order  to  give  the  same  level  in  the  burette  is 
clearly  the  volume  of  the  hand.  The  distance  to  which  the  hand 
is  to  be  inserted  into  the  calorimeter  is  fixed  by  making  a  horizontal 
mark  with  a  pencil  at  the  level  of  the  lower  border  of  the  styloid 
process  of  the  ulna.  A  parallel  mark  is  drawn  above  this  at  a 
distance  equal  to  the  combined  thickness  of  the  felt  collar  and  the 
lid  of  the  calorimeter,  and  this  second  mark  is  just  kept  in  view 
above  the  collar  during  the  experiment.  The  lower  mark  must 
then  define  the  limit  up  to  which  the  hand  is  enclosed  in  the  calori- 
meter. The  collar  is  supported  by  a  flange  around  the  orifice. 
The  temperature  of  the  arterial  blood  at  the  wrist  is  taken  as  0.5° 
below  the  rectal  temperature,  since  this  was  the  difference  actu- 
ally found  in  a  normal  person.  It  can  be  measured  by  determining 
that  temperature  of  the  calorimeter  at  which  the  hand  neither  gains 
nor  loses  heat.  Where  the  rectal  temperature  cannot  be  con- 
veniently obtained  the  mouth  temperature  is  taken  as  that  of  the 
arterial  blood  at  the  wrist.  The  temperature  of  the  venous  blood 
is  taken  as  the  average  temperature  of  the  calorimeter  during  the 
experiment,  since  direct  estimations  of  the  temperature  of  blood 
collected  by  puncture  of  hand  veins,  during  immersion  of  the 
hand  in  baths  at  known  temperatures,  showed  that  the  excess  of 
the  temperature  of  the  venous  blood  over  that  of  the  bath  was  so 
small  as  to  l)e  negligible  for  such  bath  temperatures  as  are  used 
in  the  experiments." 

The  normal  average  flow  as  determined  by  Stewart  ranged 
between  3.5  and  14  grams  of  blood  per  100  c.c  of  hand  per  minute 
at  ordinary  room  temperature,  and  with  an  immersion  of  ten  to 
fifteen  minutes.  Individual  variations  on  different  days  were  more 
or  less  constant.  Elevation  of  the  room  temperature  increased 
the  flow.  Muscular  activity  of  one  hand  produced  an  increase  of 
flow  in  that  member  over  its  fellow  in  proportion  of  nearly  three 
to  one.  Individuals  with  habitually  cold  hands  exhibited  a  lower 
rate  of  flow  than  normal  people.  A  diminished  blood  flow  also 
results  from  venous  stasis  produced  by  moderate  constriction  of 
the  wrist.    The  local  application  of  heat  increases  the  rate  of  flow. 

Even  a  moderate  amount  of  forced  breathing  decreases  blood 
flow,  in  explanation  of  which  Stewart  suggests  "acapnia  caused  by 
the  washing   out  of  the  carbon  dioxide  as  a  possible  influence." 


METHODS  OF  ESTIMATING   THE  RATE  OF  BLOOD  FLOW     173 

Mechanical  changes  in  the  thorax,  and  particularly  those  affecting 
the  filling  and  discharge  of  the  heart,  must  also  be  taken  into 
account.  One  moral  to  be  drawn  is  that  while  the  respiratory 
pump  has  a  part  of  some  consequence  in  the  normal  movement  of 
the  blood,  and  may  even  become  the  preponderant  factor  when  the 
heart  and  the  vasomotor  mechanisms  are  crippled,  the  idea  of  the 
"deep-breathing"  fanatics  that  voluntary  interference  with  the 
delicately  regulated  respiratory  mechanics  must  be  good  receives 
no  support,  at  least  so  far  as  the  circulation  in  the  periphery  is 
concerned. 

Further  findings  regarding  the  rate  of  flow  showed  a  diminished 
rate  in  cases  of  arteriosclerosis  of  long  standing;  of  brachial  neuritis 
with  muscular  atrophy;  and  of  hemiplegia  (associated  with  com- 
plete abolition  of  vasomotor  reflexes  on  the  affected  side). 

An  increased  flow  was  found  in  early  peripheral  neuritis  on  the 
affected  side,  probably  owing  to  a  paresis  of  the  vasoconstrictor 
fibers;  in  a  case  of  occupation  neuralgia;  in  case  of  an  infected 
finger  (with  partial  obliteration  of  vasomotor  reflexes);  in  exoph- 
thalmic goitre. 

The  Plethysmograph. — This  instrument  gives  us  information 
regarding  the  volume  pulse.  The  volume  of  all  organs  varies  with 
the  different  phases  of  the  cardiac  cycle  with  those  of  the  respira- 
tion and  with  vascular  tonus,  as  well  as  with  certain  psychic 
influences,  etc. 

The  Method. — The  extremity  to  be  investigated,  generally  the 
forearm,  is  introduced  into  a  glass  chamber  which  is  filled  with 
water  and  made  water-tight  by  means  of  a  rubber  cuff.  The  water 
contained  in  the  cylinder  communicates  by  means  of  rubber  tubing 
with  a  recording  piston,  the  upward  or  downward  displacement  of 
which  imparts  its  fluctuations  to  a  tambour  which  records  its 
movement  on  a  k\Tnograph.  By  this  means  the  variations  in 
volume  may  be  studied. 

The  technic  is  somewhat  complicated,  and  hence  the  plethysmo- 
graph is  hardly  likely  ever  to  become  a  popular  instrument  for 
clinical  work,  but  for  purposes  of  scientific  investigation,  thera- 
peutic effects,  etc.,  it  possesses  a  distinct  field  of  usefulness  (Fig.  73). 

The  actual  amonnt  of  blood  in  the  arm  can  be  estimated  as  sug- 
gested by  O.  IVIiiller,^  by  rendering  the  limb  bloodless  by  immersion 

'  Exper.  u.  kritische  Beitrage  zur  modernen  Kreislauf  Diagnosfik  u.  ihr  weitcrre 
Ausbau  durch  Einfiihrung  des  absoluten  Plethysmograninies,  Verhandl.  d.  Kong.  f. 
inn.  Med.,  Wiesbaden,  1907,  xxiv,  384. 


174      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

in  mercury,  and  then  applying  an  Esmarch  bandage  to  the  upper 
arm,  the  constriction  of  which  is  not  released  until  the  plethys- 
mographic  adjustment  has  been  made.  The  method  is  not  infal- 
lible, however,  as  the  primary  anemia  tends  to  the  production  of 
a  secondary  hyperemia.     Some  interesting  results  were  obtained 


Fig.  73. — The  plethysmograph :     A,  cuff;  B,  recording  tambour;  C,  chronograph; 
D,  drum.     (After  Hoffmann.) 


with  the  plethysmograph  by  Weber,  who  was  able  to  show  the 
effect  of  psychic  stimuli  on  blood  distribution.  For  instance  a 
concentration  of  attention  upon  the  arm — the  subject  being  told 
to  imagine  he  was  performing  muscular  actions  with  it — is  attended 
by  an  increased  flow  to  the  part. 


METHODS  OF  ESTIMATING  THE  RATE  OF  BLOOD  FLOW     175 


Miiller  has  constructed  the  following  table  showing  the  effects 
of  different  stimuli  on  blood  distribution : 


Periphery 

Abdominal 

Extreiriities 

Brain. 

of  head. 

organs. 

etc. 

Cold + 

- 

+ 

- 

Warmth 

- 

+ 

— 

+ 

Chloroform 

+ 

— 

+ 

— 

Adrenalin 

+ 

— 

— 

— 

Desire 

+ 

+ 

— 

+ 

Disgust 

— 

— 

+ 

- 

Fright 

+ 

— 

+ 

— 

Mental  effort 

+ 

— 

+ 

— 

Sleep    . 

+ 

+ 

— 

+ 

Imaginary  exe 

rcis 

es 

+ 

— 

— 

+ 

Fig.  74. — The  finger  plethysmograph.     (Fleischer.) 

A  small  finger  plethysmograph  has  been  devised  by  Fleischer,' 
It  must  be  borne  in  mind  that  deductions  drawn  from  plethys- 
mographic  readings  can  be  applied  only  to  the  limb  in  question,  not 
the  system  as  a  whole.  Particularly  useful  data  may  be  obtained 
if  such  observations  are  made  simultaneously  with  blood-pressure 
observations  (Fig.  74). 

The  plethysmograph  gives  us  data  regarding  the  peripheral  cir- 
culation but  tells  us  nothing  as  to  the  underlying  causes  which 
produce  them,  as  to  whether  variations  are  due  to  an  abnormal 

1  Berl.  klin.  Wchnschr..  1908. 


176      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 


elasticity,  or  a  small  arterial  bed,  and  as  to  whether  these  changes 
are  normal  for  the  individual  or  pathological  manifestations.  IIow 
great  a  part  is  taken  by  vasomotor  tone,  and  whether  the  stimuli 
causing  these  changes  arise  in  the  spinal  cord  or  in  the  peripheral 
ganglia,  or  whether  the  fault  lies  in  the  capillaries  or  veins;  upon 
these  questions  we  vainly  seek  for  information. 

A.  Miiller^  has  suggested  that  systolic  ovt- 
put  might  be  gauged  by  the  determination  of 
the  venous  pressure. 

The  Method. — ^The  circulation  in  the  arm 
is  arrested  by  the  sudden  inflation  of  the 
brachial  cuff  from  a  large  bottle  containing 
air  under  pressure.  The  venous  pressure  is 
now  measured  by  the  Basch-Recklinghausen 
method,  which  gives  us  the  resistance  {W) 
which  the  succeeding  arterial  pressure  must 
overcome.  The  arm  is  next  placed  in  a 
plethysmograph  above  which  another  cuff 
is  applied  and  inflated  to  about  50  mm. 
Hg.,  a  pressure  well  below  the  minimum 
pressure  and  which  therefore  does  not  inter- 
fere with  arterial  inflow,  although  it  does 
with  venous  outflow.  The  pressure  in  the 
upper  cuff  is  now  suddenly  dropped  to  0, 
the  arterial  blood  flows  into  the  arm  but 
cannot  flow  out  of  its  vein  until  the  venous 
pressure  rises  above  that  in  the  cuff  (50 
mm.).  Until  this  occurs  the  arm  is  in  a 
hydrostatic  condition  and  the  resultant 
sphygmographic  curve  will  be  a  curve  of 
arterial  outflow  (F)  (Fig.  75). 

Under  these  conditions  the  pressure  in  the 
occluded  region  will  be  a  measure  of  the  resistance  (W)  against 
w^iich  the  outflowing  blood  stream  operates  when  the  obstruction 
is  removed.  The  second  cuff  which  measures  the  venous  pressure 
does  not  interfere  with  the  inflow  but  prevents  for  a  time  the 
onward  flow  of  venous  blood.  The  height  of  the  first  volume  pulse 
indicates  the  value  of  V.  If  bodily  weight  and  mean  pressure 
are  known,  we  can  calculate  V  the  systolic  output,  and  V  D,  the 
cardiac  work. 


Fig.  75. — Plethysmo- 
graphic  curve  used  to 
determine  Vi  (the  arterial 
flow  into  the  arm, against 
the  resistance  W). 


*  Ueber  Schlagvolumen  u.  Herzarbeit  des  Menschen,  Deutsch.  Arch.  f.  klin.  Med., 
1909,  xcvi,  127. 


METHODS  OF  ESTIMATING  THE  RATE  OF  BLOOD  FLOW     177 

Using  this  method  Miiller  found  that  the  systolic  output  averaged 
85  c.c.  for  men  and  25  c.e.  for  women.  An  increase  was  found  in 
nephritis,  cardiovascular  disease,  exophthalmic  goitre,  and  Addison's 
disease. 

This  method  has  been  criticised  as  theoretically  faulty  by  Christen 
and  the  practical  results  have  varied  considerably  from  those  of 
Plesch.i 


Fig.  76. — Hewlett  and  Van  Zwaluwenburg's  method  for  estimating  the  rate  of 
blood  flow.  Diagram  of  apparatus  for  determining  the  rate  of  blood  flow  through 
the  arm.  The  arm  is  placed  in  the  plethysmograph  P,  the  opening  of  which  is  closed 
by  a  piece  of  rubber  dam  D,  and  the  connection  with  the  skin  made  tight  with 
soapsuds.  The  narrow  pressure  cuiT  C  is  placed  around  the  arm  about  3  cm.  above 
the  opening  into  the  plethysmograph.  The  pressure  cuff  is  inflated  by  opening  the 
stopcock  connecting  it  with  the  large  bottle  A,  in  which  the  pressure  has  previously 
been  raised  by  the  rubber  bulb  B.  Pressures  are  read  by  the  spring  manometer 
M.  The  plethysmograph  is  connected  with  the  volume  recorder  V,  which  writes 
upon  a  moving  drum.  Air  can  be  let  out  of  the  system  by  the  stopcock  X,  and 
water  can  be  introduced  from  the  burette  Y,  so  that  the  writing-point  of  the  volume 
recorder  can  be  adjusted  at  will.  The  stopcock  Z  serves  to  disconnect  the  plethys- 
mograph from  the  recording  apparatus  during  adjustments  of  the  former.  The 
recording  apparatus  is  graduated  by  allowing  5  c.c.  of  fluid  at  a  time  to  flow  in 
from  the  burette,  and  marking  the  elevation  of  the  volume  recorder  thus  produced. 


A  somewhat  similar  method  of  procedure,  based  on  the  method 
of  Brodie,2  has  been  proposed  by  Hewlett  and  Van  Zwaluwenburg,^ 
to  determine  the  rate  of  blood  flow  (Fig.  76) . 

The  arterial  blood  enters  the  organ  with  undiminished  speed  at 
first,  but  soon  the  flow  is  retarded  by  the  rise  of  pressure  in  the 
veins  and  capillaries.     The  organ  therefore  swells  rapidly  at  first 

1  Hemodynamische  Studien,  Berlin,  1909. 

2  The  Determination  of  the  Rate  of  Blood  Flow  Through  an  Organ,  Reported 
at  the  Seventh  International  Physiological  Congress,  August,  1907.  (Brodie  esti- 
mated the  blood  flow  in  an  organ  by  suddenly  occluding  its  peripheral  vein  and 
measuring  the  change  of  volume  by  means  of  an  oncometer.) 

'  The  Rate  of  Blood  Flow  in  the  .\rm,  Heart,  i,  87. 
12 


178      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

and  progressively  more  slowly.  The  earliest  portion  of  this  curve 
represents  the  rate  at  which  the  blood  enters  under  normal  condi- 
tions. Brodie  has  shown  that  this  method  gives  as  reliable  results 
as  the  Stromiihr.  , 

The  following  method  of  testing  the  circulation  time  has  been 
suggested  by  Bornstein.^  The  patient  is  made  to  breathe  CO2  and 
the  time  is  noted  at  which  the  respirations  become  more  forcible. 
This  indicates  the  time  taken  by  the  blood  to  pass  through  the 
lung  and  left  heart  and  to  reach  the  respiratory  centre;  it  is  assumed 
to  be  equivalent  to  half  the  entire  circuit.  In  health  the  half- 
circuit  is  completed  in  from  twelve  to  sixteen  seconds,  much  less 
time  being  required  after  muscular  effort,  deep  breathing  and  the 
inhalation  of  nitrite  of  amyl. 

Fellner^  believes  that  the  rapidity  of  flow  may  be  estimated  by 
measuring  with  a  stop-watch  the  length  of  time  required  for  the 
blood  to  reach  the  fingers — travel  50  cm. — after  the  release  of 
tension  in  a  pneumatic  cuff  applied  to  an  arm  previously  rendered 
bloodless  by  bandaging.  This  method  is  open  to  many  criticisms. 
(1)  The  air  escapes  from  the  cuff  too  gradually.  (2)  The  vessels 
have  been  previously  emptied  and  therefore  do  not  offer  the  natural 
resistance  to  the  flow.  (3)  The  blood  path  from  the  brachial  to 
the  digital  arteries  is  not  direct,  owing  to  the  branching  and  steady 
diminution  in  caliber  of  the  arterial  tree. 

The  Krogh-Lindhard  Method. — "The  principle  involved  is,  briefly, 
to  determine  the  rate  of  absorption  of  nitrous  oxide  in  the  lungs. 
Since  nitrous  oxide  is  a  readily  soluble  gas,  yet  one  which  forms  no 
chemical  combination  with  hemoglobin,  it  will  go  into  solution  at 
body  temperature  according  to  a  definite  coefficient.  This  coeffi- 
cient has  been  determined  by  Siebeck.  This  being  true,  if,  after 
having  breathed  a  mixture  of  air  and  nitrous  oxide,  the  subject 
holds  his  breath  for  a  certain  length  of  time,  and  we  then  deter- 
mine the  percentage  of  nitrous  oxide  in  the  alveolar  air  at  the  begin- 
ning and  at  the  end  of  this  period,  together  with  the  total  amount 
of  gas  enclosed  in  the  chest  during  the  period  of  holding  the  breath, 
we  can  calculate  how  much  blood  must  have  passed  through  the 
lungs  to  remove  the  amount  of  nitrous  oxide  which  has  disap- 
peared."^ 

'  Eine  klinische  Methode  z.  Schiitzung  d.  Kreislaufzeit,  Miinchen.  nied.  Wchnschr., 
1912,  lix,  1486. 

^  Das  Fulsome ter,  ein  prakt.  Instrument  z.  Bestimmung  d.  Stromgeschwindig- 
keit  des  Blutes  am  lebenden  Menschen,  Deutsch.  med.  Wchnschr.,  1907,  No.  15. 

'  Means,  J.  H.,  and  Newburgh,  L.  H.:  Studies  of  the  Blood  Flow  by  the  Method 
of  Krogh  and  Lindhard,  Tr.  Assn.  Am.  Phys.,  1915,  xxx,  51. 


METHODS  OF  ESTIMATING  THE  RATE  OF  BLOOD  FLOW     179 

A  modification  of  this  method  has  been  devised  by  Means  and 
Newburgh,  which  consists  of: 

1.  The  oxygen  absorption  (this,  .  .  .  was  done  by  a  short 
experiment  with  the  Douglas  bag). 

2.  The  hemoglobin  and  consequently  the  oxygen  capacity  (by 
the  Hellige  colorimeter     .     .     .     ). 

3.  The  percentage  saturation  of  the  venous  blood  with  oxygen. 

4.  The  pulse  rate. 

"The  third  determination,  that  of  the  percentage  saturation  of 
the  venous  blood  with  oxygen,  is  obtained  by  withdrawing  a 
sample  of  blood  from  an  arm  vein  into  a  syringe  containing  a  little 
potassium  oxalate  solution,  and  from  which  all  air  bubbles  have 
been  expelled.  (We  also  found  it  well  to  grease  the  plunger  of  the 
syringe.)  From  this  syringe  the  blood  was  directly  introduced 
beneath  the  ammonia  solution  in  one  of  the  bottles  of  the  Barcroft 
differential  blood-gas  apparatus,  without  being  exposed  at  any  time 
to  the  air.  Its  percentage  saturation  with  oxygen  was  thereupon 
determined. 

"Having  obtained  these  factors  we  proceeded  to  calculate  the 
blood  flow.  In  the  light  of  Barcroft's  determinations  of  the  oxygen 
content  of  arterial  blood,  we  have  assumed  that  the  blood  leaves 
the  lungs  94  per  cent,  saturated.  If  then  the  percentage  saturation 
of  the  venous  blood  is  found  to  be  60  per  cent,  the  coefficient  of 
utilization  of  the  oxygen  capacity  will  be  the  difference  between 
the  two,  or  34  per  cent.  Knowing  the  oxygen  absorption,  the 
coefficient  of  utilization,  and  the  oxygen  capacity,  we  calculate 
the  blood  flow  from  the  formula: 

„,     J  „  .      ^  O2  absorption  per  minute 

Blood  now  per  minute  = ^ — 

(coefficient)  (oxygen  capacity) 

and  the  volume  per  beat : 

^r  ,  ,      .        Blood  flow  per  minute 

Volume  per  beat  = 

Pulse  rate 

The  accuracy  of  the  method  depends  entirely  upon  whether  the 
percentage  saturation  of  the  blood  in  the  arm  vein  is  any  criterion 
of  that  in  the  right  heart.  At  the  present  time  we  are  unable  to 
say  positively  whether  this  is  true,  and  consequently  only  propose 
this  method  tentatively.  We  believe,  however,  that  it  is  a  fair  cri- 
terion, and  base  this  belief  in  part  upon  two  animal  experiments 
in  which  we  took  samples  of  venous  blood  from  different  localities 
and  found  a  fairly  close  percentage  saturation  in  the  different 
samples." 


180      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

Using  this  method  the  last-named  authors  found  in  two  normal 
subjects  a  rest  flow  of  4  to  4^  liters  per  minute.  In  response  to 
increasing  amounts  of  work  the  blood  flow  rose  to  15  litres  per 
minute. 

The  Tachograph. — The  hlood  flow  in  the  arm  may  also  be  esti- 
mated by  means  of  a  sensitlte  flame.  Von  Kries's  instrument, 
devised  for  this  purpose,  is  known  as  the  tachograph.^  "The  fore- 
arm is  inserted  into  an  air-tight  glass  cylinder,  but  in  this  case  no 
water  is  introduced.  With  each  systole  of  the  heart  a  certain 
amount  of  air  is  forced  out  of  the  cylinder  through  the  rubber 
tubing  into  a  specially  devised  gasoline  burner.  The  expelled  air 
causes  the  gasoline  flame  to  flare  upward  to  a  height  proportional 
to  the  amount  of  air  displaced.  This  flame  is  in  turn  photographed 
upon  a  revolving  strip  of  paper  sensitized  with  bromide  of  silver. 
When  the  tracing  is  developed  it  presents  a  succession  of  zigzags 
at  first  glance  resembling  the  results  of  the  electrocardiogram" 
(Fig.  77). 

When  the  arm  increases  in  volume  during  the  ventricular  systole, 
the  enclosed  air,  meeting  with  no  resistance  to  outflow  through 
the  tubing  will  emerge  the  more  rapidly  and  suddenly  the  more 
quickly  the  blood  is  forced  into  the  arm  (Figs.  78,  79  and  80). 

The  Estimation  of  Resistance  in  the  Large  Vessels. — Brocking^ 
made  brachial  blood-pressure  observations  in  the  following  postures : 
A,  recumbent;  B,  sitting  in  bed  with  the  legs  extended;  C,  sitting 
with  the  legs  dependent;   D,  standing. 

Normally,  the  pressure  is  highest  in  B,  which  he  explains  as 
due  to  a  compensatory  peripheral  contraction  instituted  to  prevent 
splanchnic  anemia.  It  is  further  increased  by  pressing  the  legs 
against  the  abdomen.  If  there  be  circulatory  weakness,  the  maxi- 
mum pressure  in  B  is  lower  than  in  A ,  showing  a  loss  of  peripheral 
arterial  power. 

The  Estimation  of  Arterial  Functionation. — O.  Miiller  employs  the 
following  method:  The  arm  is  introduced  into  a  plethysmograph 
and  ice  is  applied  to  the  arm  above  the  instrument.  Normal  arteries 
show  a  distinct  diminution,  and,  upon  withdrawal  of  the  cold,  an 
increase  in  volume.  In  sclerotic  arteries  these  changes  are  in  part 
or  entirely  lacking.  This  test,  although  for  the  most  part  corrobo- 
rated by  other  investigators  has  also  been  criticised. 

*  Ein  Neuea  Verfahren  z\xr  Beobachtung  der  Wellenbewegung  des  Blutes,  Berl. 
klin.  Wchnschr.,  1887,  p.  589. 

*  Ein  Beitrag  zur  Funktionspriifung  der  Arterien,  Ztschr.  f.  exp.  Path.  u.  Therap., 
1907,  iv,  Pt.  I. 


Fig.  77. — The  tachograph  of  von  Kries:     A,  cu£f ;  B,  sensitive  flame;  C,  camera. 


Fig.  79. — Central  tachogram,  reading  from  right  to  left:     a,  at  rest;  b,  after 
exercise.     (Miiller  and  Veiel.) 


Fig.  80. — a,  central  tachogram  in  aortic  insufficiency;  b,  peripheral  tachogram  in 
aortic  obstruction. 


182      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

Cold  contracts  and  heat  dilates  the  arteries  of  healthy  people 
but  the  psychic  state  also  plays  a  considerable  part.  It  is  therefore 
necessary  to  arrange  plethysmographic  examinations  in  such  a 
manner  that  thermic  and  psychic  influences  shall  not  be  separated. 
Even  if  after  repeated  trials  the  vessels  do  not  react  one  cannot  on 
that  account  diagnosticate  an  anatomical  lesion.  One  cannot  con- 
clude that  a  man  is  arteriosclerotic  because  his  vessels  do  not  react 
to  ice,  because  many  organic  cardiac  maladies  do  not  give  this 
response,  but  merely  that  his  arterial  functionation  is  not  normal. 
In  the  majority  of  individuals  hardened  arteries  are  hyporeactional, 
or  even  areactional  to  ice,  although  some  of  them  are  hyper- 
reactional.^ 


Fig.  81. — A.  kymograph;  B,  plethysmograph  of  Mosso;  B',  plethysmograph  of 
Wiersma;  C,  cuff;  D,  manometer;  E,  pump;  F,  escapement;  a,  tambour  with  pen; 
b,  escapement;  c,  occlusive  rubber  cuff;  d,  stopcock;  e,  three-way  glass  tubing. 


The  Estimation  of  Vascular  Tonus.— De  Vries-Reilingh^  suggests 
the  following  method  for  determining  the  degree  of  arterial  tonus: 

A  small  cuff  is  applied  to  the  arm  while  the  forearm  is  placed 
in  a  plethysmograph.  Pressure  is  suddenly  raised  above  the  systolic 
pressure  in  the  upper  cuff.  The  tambour  of  the  plethysmograph 
now  registers  a  straight  line;  but  as  soon  as  pressure  in  the  cuff' 
falls  sufficiently  to  allow  blood  to  pass  through,  the  tambour  will 
rise.  The  pressure  at  this  point  is  the  maximum  arterial  pressure 
plus  the  arterial  tonus.  If  pressure  is  gradually  lowered  a  further 
rise  of  the  tambour  due  to  venous  stagnation  will  occur.  But  in 
time  a  point  will  be  reached  at  which  the  tambour  falls  because 
the  cuff  pressure  has  become  less  than  the  venous  pressure.  The 
difference  in  pressure  between  the  first  elevation  and  the  first  fall 
of  the  tambour  is  taken  as  the  index  of  vascular  resistance.  This 
factor  was  found  to  range  between  17  and  32  mm.  Ilg.,  the  normal 
average  being  18  mm.    A  source  of  error  lies  in  the  fact  that  during 

'  Romberg,  B.,  and  Milller,  O.:  Ueber  d.  Bedeutung  u.  Technik  d.  Plethysphyg- 
mographischcn  Funktionspriifung  gesunder  u.  kranken  Arterien,  Ztschr.  f.  klin. 
Med.,  1912,  Ixxv,  92. 

2  Zur  Blutdruckmessung,  Ztschr.  f.  klin.  Med.,  1913,  Ixxvii,  67. 


METHODS  OF  ESTIMATING  THE  RATE  OF  BLOOD  FLOW     183 

this  prolonged  procedure  for  some  reason  a  general  increase  of 
pressure  occurs.  This  rise  of  pressure  renders  an  estimation  of  the 
minimal  pressure  unreliable,  and  while  such  a  rise  may  be  obviated 
by  placing  the  cuff  at  the  distal  end  of  .the  forearm,  a  new  source 
of  error  is  thus  introduced  by  the  protected  position  of  the  arteries 
at  this  point.  The  results  would  probably  also  vary  according  to 
the  rate  at  which  the  cuff  pressure  was  lowered  (Fig.  81). 

The  Diastolic  Index. — It  has  been  suggested  that  some  light  might 
be  thrown  upon  vasomotor  responses  by  observing  the  diastolic 
pressure  as  recorded  while  manometric  pressure  is  being  (1) 
increased,  (2)  decreased.  Macwilliam  and  Melvin^  found  that 
different  readings  (20  mm.  Hg.)  are  sometimes  thus  obtained.  They 
construe  this  phenomenon,  which  is  a  rarity,  as  a  result  of  sluggish 
vasomotor  response  to  obliteration  of  a  large  arterial  branch.  It 
occurs  more  frequently  if  simultaneous  readings  are  made  on  both 
arms. 

The  Estimation  of  Capillary  Blood-pressure. — ^Various  and  for  the 
most  part  unsatisfactory  methods  of  measuring  capillary  pressure 
have  been  suggested  (see  page  144).  We  have  had  no  personal 
experience  with  the  determination  of  the  capillary  tension,  but  it  is 
manifest  that  if  a  method  can  be  devised  which  is  both  accurate 
and  clinically  applicable  much  valuable  information  will  be 
obtained.  Simultaneous  observations  on  the  relationship  between 
the  arterial  and  the  venous  pressures  yield  more  important  data 
regarding  the  state  of  the  circulation  than  either  alone,  since  the 
arterial  represents  the  beginning  and  the  venous  the  end  of  the 
greater  circulation. 

Combined  Observations. — A  more  accurate  though  clinically  inap- 
plicable method  of  functional  diagnosis  originally  described  by 
Marey  and  lately  rejuvenated  by  O.  Miiller,  Romberg,  and  F. 
Kraus,  consists  of: 

1.  Prolonged  continuous  observation  of  the  systolic  and  diastolic 
pressures. 

2.  Continuous  tachographic  observation  undertaken  simultane- 
ously with  the  foregoing. 

If  both  pressure  and  rate  increase  it  is  assumed  that  we  are 
dealing  with  an  increased  systolic  output;  if  the  two  values  move 
in  opposite  directions,  that  an  alteration  of  peripheral  resistance  in 
the  arm  under  observation  has  occurred. 

3.  Plethysmographic  observations  to  determine  vascular  changes 
in  the  arm. 

'  Some  Observations  on  the  Significance  of  Blood-pressure  Readings  in  Man, 
British  Med.  Jour.,  November  7,  1914,  p.  2818. 


184      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

But  even  this  method  does  not  permit  us  to  draw  deductions 
which  can  be  expressed  in  actual  figures. 

The  Sphygmobolometer. — This  instrument,  devised  by  SahH/  is 
used  to  estimate  the  energy  of  ^indimdual  pulse  wares,  and  thus 
indirectly  the  energy  of  cardiac  systole. 


Fig.  82. — Schematic  diagram  of  Sahli's  sphygmobolometer:  A,  cuff;  6,  inflating 
bull);  C,  mercurial  manometer;  E,  graduated  piston  pump;  d,  index  manometer. 
Lower  diagrams:  A,  lateral  view  of  the  steel  cuff;  E,  index  manometer  in  horizontal 
and  erect  position. 

The  Principle. — ^The  pulse  wave  is  made  to  transmit  its  force  to 
a  measured  quantity  of  air  enclosed  in  a  cuff  (A)  encircling  the 
forearm  and  communicating  with  a  manometer.  The  pressure 
in  the  cufT  is  raised  until  the  maximum  oscillation  occurs  in  the 
oscillator  (d),  this  point  being  known  as  the  optimum  pressure. 


»  Sahli's  Diagnostic  Methods,  1911,  p.  186. 


METHODS  OF  ESTIMATING  THE  RATE  OF  BLOOD  FLOW     185 

This  is  accomplished  through  the  use  of  a  steel  outer  cuff,  with 
which  tension  can  be  very  exactly  regulated  and  the  precise  point 
noted  at  which  the  maximum  oscillation  is  overstepped. 

The  energy  of  that  portion  of  the  aortic  wave  which  reaches  the 
brachial  artery  is  expended  in  three  directions:  (1)  That  which 
passes  the  cuff".  (2)  That  which  is  reflected  backward  toward  the 
heart.  (3)  That  which  compresses  the  cuff.  Manifestly  only  the 
latter  portion  can  be  measured,  thus  ever  leaving  two  undetermin- 
able factors. 

By  observing  the  actual  height  of  the  manometric  pressure  which 
corresponds  to  the  optimum  pressure,  by  noting  the  extent  of 
oscillation  of  the  latter,  and  knowing  the  volume  of  the  enclosed 
air,  we  are  enabled  to  construct  a  formula  which  represents  the 
amount  of  energy  expended.  The  volume  of  air  is  measured  by 
means  of  a  graduated  piston  syringe  (£)  with  a  capacity  of  200  c.c. 
The  cubic  capacity  of  the  index  manometer  is  determined  for  each 
individual  instrument,  the  lumen  being  calibrated  in  such  a  manner 
that  each  centimeter  of  length  is  equivalent  to  0.02  c.c.  The  instru- 
ment is  based  upon  Boyle's  (Mariotte's)  law  that  if  temperature 
remains  constant  the  volume  of  gas  will  vary  inversely  as  the 
pressure,  whence  follows  the  formula : 

W  =  work  performed  by  each  pulse  wave. 
V  =  volume  of  air. 
(A  p)  =  maximum  oscillation  reduced  to  cm.  Hg. 

B  =  mean  barometric  pressure  =  76.4  (New  York). 
P  =  pressure  in  cm.  Hg.  at  maximum  excursion  of  index  manometer. 
/       R       \  /       P      \ 

13.6 


\B  +  P/ 

\B  +  Pj 

P. 

F. 

5 

0.78 

6 

0.92 

7 

1.04 

8 

1.16 

9 

1.28 

10 

1.39 

11 

1.49 

12 

1.59 

13 

1.69 

14 

1.78 

15 

1.87 

16 

1.95 

17 

2.02 

18 

2.10 

19 

2.17 

20 

2.23 

21 

2.30 

22 

2.36 

23 

2.42 

A  table  can  be  worked  out  so  that  each  estimation  requires  but 
one  multiplication:  {A  j))  X  {F  X  V). 


186      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 


The  accuracy  of  any  single  determination  depends  mainly  on 
the  reading  of  (A  />),  errors  in  the  other  terms  being  negligible  in 
comparison.  This  involves  a  reading  of  the  excursions  of  the  kero- 
sene index  and  a  calibration  of  these  excursions  in  terms  of  mer- 
cury. Computations  show  that  under  normal  conditions  results 
obtained  by  an  experienced  observer  can  be  relied  on  to  better 
than  10  per  cent.  (Potter).^ 


Fig.  83. — The  sphygmobolometer.  The  rubber  bag  D  is  appHed  over  the  radial 
artery  by  the  cuff  H  and  connects  by  means  of  tubing  with  the  (1)  10  c.c.  syringe 
G  and  (2)  with  the  index  manometer  E,  F,  which  contains  colored  kerosene  and 
(3)  with  the  vertical  manometer  A.     (Sahli.) 


"The  value  of  i?  in  a  given  locality  may  be  assumed  to  be  con- 
stant, as  may  also  the  volume  V  for  a  given  instrument.  A  similar 
table  would  have  to  be  worked  out  for  each  individual  instrument. 

W  =  F  XV  X{/!\  p) 

"  The  total  work  of  the  pulse  per  minute  is  obtained  by  multiply- 
ing the  work  of  a  single  beat  by  the  pulse  rate.  We  are  of  course 
not  measuring  the  entire  energy  of  the  heart  but  only  that  fraction 
of  it  which  is  consumed  in  furnishing  the  pulse  wave  in  the  brachial 
cuff — this  Sahli  believes  to  be  a  constant  fraction. "^ 

'  Jour.  Am.  Med.  Assn.,  April  19,  1913,  p.  1211. 

'  For  more  detailed  discussion  see  Sahli:  Deutsch.  med.  Wchnschr.,  1907,  No.  16, 
p.  628;  No.  17,  p.  665.  Salili:  Diagnostic  Methods,  edited  by  Potter,  W.  B.  Saun- 
ders Company,  Philadelphia,  2d  ed.  Sahli:  Deutsch.  mcd.  Wchnschr.,  1910,  No. 
47,  p.  2181.  Christen:  Ztschr.  f.  klin.  Med.,  1910,  Ixxi,  390.  Sahli:  Ztschr.  f. 
klin.  Med.,  1911,  Ixxii.  1.  Sahli:  Ztschr.  f.  klin.  Med.,  1911,  Ixxii,  214.  Christen: 
Ztschr.  f.  klin.  Med.,  1911,  Ixxiii,  55.  Christen:  Deutsch.  med.  Wchnschr.,  1911, 
No.  14,  p.  644.  Christen:  Cor.-Bl.  f.  schweiz.  Aerzte,  1911,  p.  562.  Sahli:  Ztschr. 
f.  klin.  Med.,  1912,  Ixxiv,  2.S0,     Christen:   Ztschr.  f.  klin.  Med.,  1912,  Ixxiv,  447. 


METHODS  OF  ESTIMATING  THE  RATE  OF  BLOOD  FLOW     187 

The  most  recent  modification  of  sphygmobolometry^  consists  in 
the  substitution  of  a  Jacquet  sphygmograph  equipped  with  a  spiral 
spring  in  place  of  a  pneumatic  cuff.  The  coefficient  of  elasticity 
of  the  spring  is  practically  constant  for  different  pressures,  hence 
it  is  possible  to  take  the- arithmetic  mean  of  the  beginning  and 
end  tension  of  the  pressure.  In  order  to  translate  the  spring  ten- 
sion into  grams  the  apparatus  is  equipped  with  a  device  to  draw 
upon  the  smoked  paper  nine  parallel  abscissae.  For  each  of  these 
abscissie,  the  pressure  value  of  the  spring  is  established  in  grams 
and  tabulated.  These  abscissae  indicate  the  height  of  the  pelotte 
plus  the  magnification  due  to  the  tambour.  Thus  it  is  possible  to 
take  tracings  of  different  degrees  of  spring  pressure,  choosing  those 
as  our  criteria  which  yield  the  largest  work  product.  Needless  to 
say,  a  sphygmograph  must  be  applied  with  accuracy  and  care. 

Dsmamic  Diagrams. — T.  F.  Christen  suggests  the  use  of  "dynamic 
diagrams"^  as  an  index  of  cardiac  work,  a  conception  which  he 
bases  on  the  follow^ing  h\'pothesis: 

The  Theory. — The  old-fashioned  palpation  of  the  pulse  tells  us 
much  more  about  the  condition  of  the  circulation  than  does  the 
sphygmogram,  in  spite  of  the  latter's  seemingly  higher  scientific 
character.  In  the  clinical  sphygmogram  there  is  no  exact  relation 
between  the  ordinates  and  the  pressures.  We  do  not  even  know 
where  to  trace  the  level  of  the  pressure  zero.  Even  if  there  were 
such  a  relation,  sphygmography  would  still  not  be  a  dynamic 
method,  as  in  dynamics  we  do  not  have  to  study  alone  the  temporal 
variations  of  the  forces,  but  essentially  the  effect  of  these  forces. 
These  two  statements  sufficiently  explain  the  failure  of  the  clinical 
sphygmogram.  There  are  two  dynamic  diagrams  of  the  pulse  that 
may  be  determined  in  a  mathematically  exact  manner.  They  are 
the  graphic  expression  of  clinical  experiments  based  upon  the  fol- 
lowing two  questions :  (a)  What  is  the  systolic  increase  of  volume  of 
the  arteries  covered  by  a  pneumatic  cuff  by  a  given  pressure?  (6) 
What  is  the  amount  of  mechanical  energy  required  for  this  move- 
ment? These  dynamic  diagrams,  called  stasis  curves,  are  charac- 
teristic of  the  behavior  of  the  pulse  against  a  stasis  pressure.  They 
depend  on  the  volume  of  air  within  the  cuff  as  little  as  they  do  on 
the  elasticity  of  the  cuff  and  the  soft  parts.  They  depend  only  on 
the  breadth  of  the  cuff.     We   therefore   have  to  compare  stasis 

1  Lipowetsky,  L. :  Sphygmobolonietrische  Untersuchungen  an  Gesunden  und 
Kranken  mittels  des  Sahlischen  sphygniobolographischen  Verfahreiis,  Deutsch. 
Arch.  f.  klin.  Med.,  1913,  cix,  S.  498-514. 

2  Die  neuen  Methoden  d.  Dynamischen  Pulsdiagno.stik,  Ztsfhr.  f.  klin.  Med.,  1911, 
Ixxviii,  55. 


188      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

curves  derived  from  experiments  with  cuffs  of  the  same  breadth. 
The  exchisive  consideration  of  pressure  and  its  temporal  variations 
will  never  permit  us  to  solve  the  question  of  diagnosis  of  the  pulse, 
for  the  mechanics  of  the  pulse  .contain  essentially  dynamic  prob- 
lems more  than  any  other  province  of  physiology.  The  stasis 
curves  (dynamic  diagrams)  replace  the  palpation  of  the  pulse  by 
an  exact  method,  because  they  answer  the  same  questions  that 
palpation  does,  informing  us  concerning  the  "filling"  and  the 
"intensity"  of  the  pulse.  The  method  depends  on  the  estimation 
of  the  force  necessary  to  produce  the  oscillations  which  are  observed 
in  the  determination  of  the  pulse-pressure.  This  variation  in  the 
volume  of  the  artery  does  not  depend  on  the  volume  of  air  within 
the  cuff,,  nor  on  the  elasticity  of  the  system.  It  can  depend  only 
on  pressure  exerted  by  the  inflated  cuff  and  on  the  dynamic 
qualities  of  the  pulse. 

The  Method. — In  order  to  find  the  value  of  the  systolic  increase 
of  volume,  i.  e.,  the  volume  of  blood  the  pushing  forth  of  which 
against  the  pressure  of  the  cuff  produces  the  oscillations  observed 
on  the  manometer,  we  make  use  of  a  syringe  whose  piston  has  to 
be  pushed  in  up  to  the  point  where  the  oscillations  have  been 
displaced  about  once  their  own  amplitude. 

Example.— \\e  observe  on  the  manometer  oscillations  between 


the  limits  170  and  176.     (The  unit  of  the  manometer  is 

\  cm 

Pushing  in  the  piston  of  the  syringe  we  increase  the  pressure  within 

the  cuff,  elevating  both  limits  of  these  oscillations.    We  do  this  in 

such  a  manner  as  just  to  reach  the  point  where  176  has  become 

the  lower  limit  of  the  oscillations,  having  been  heretofore  its  upper 

limit.    Thus  we  are  sure  that  the  volume  of  the  piston,  which  is 

read  off  on  its  own  scale,  must  be  that  incompressible  volume 

which  brought  under  the  cuff"  increases  the  pressure  within  it  from 

170  to  176.    Two  incompressible  volumes,  which,  forced  into  the 

same  air-chamber  produce  the  same  increase  of  pressure  within  it, 

must  be  equal.     Therefore  the  volume  read  off  and  the  piston 

must  be.  equal  to  the  systolic  increase  of  volume  of  the  artery  (or 

arteries)  that  is  covered  by  the  inflated  cuff.    Suppose  that  we  read 

a  volume  of  0.7  cm.',  then  the  mechanical  energy  required  for  the 

same  increase  of  volume — the  main  pressure  being: 

ev.  cr. 

173  -=-—  -  must  have  the  value  173   -— ^  X  0.7  cm.'  =  121  gr.  cm. 
cm.'  cm.2 

In  this  way  we  find  for  every  pressure  (P)  a  volume  (F)  and  an 
energy  {E),  the  relation  between  which  is  E  =  PV.     Repeating 


METHODS  OF  ESTIMATING  THE  RATE  OF  BLOOD  FLOW     189 

this  experiment  at  different  pressures  we  get  a  series  of  pressure 
volumes  and  energies  which  we  arrange  in  the  following  manner: 


Example 


ressure. 

Volume 

80 

0.1 

120 

0.3 

140 

0.55 

166 

0.9 

190 

1.2 

210 

1.2 

225 

0.9 

240 

0.4 

250 

0.2 

Energy. 

8 

36 

77 

149 

228 

252 

203 

96 

50 


"~ 

'~ 

■ 

. 

V- 

— 1 

L. 

-J 

\ 

A 

/ 

>^ 

^ 

^ 

V— Z.OCM. 

/ 

/ 

\ 

/ 

/ 

\ 

\ 

/ 

\ 

h- 

\ 

r 

■* 

\ 

\ 

1 

1 

A 

? 

Y 

1 0 

/ 

/ 

N 

C< 

r' 

/ 

\) 

r 

/ 

\ 

1. 

/ 

,-^ 

A 

\ 

/ 

^ 

^ 

\ 

/ 

Y^ 

'A 

i 

\ 

r/ 

k 

^ 

^ 

\ 

V 

f' 

^ 

f^ 

y^ 

^ 

\ 

Y^ 

^ 

V' 

P=50 


100 


lao 


200 


2.-)0 


300 


zv- 


Fig.  84. — Dynamic  diagram-s.  Curve  of  volume:  I,  that  of  health;  2,  of  myo- 
carditis; 5,  of  aortic  insufiBciency;  k,  of  arteriosclerosis.  In  cases  of  forcible  pulsa- 
tion— arteriosclerosis,  aortic  insufficiency — the  volumes  may  exceed  2  cm.  and  the 
energy  600  gr.  cm.  Furthermore,  the  character  of  the  summit  is  quite  different 
from  that  of  arteriosclerosis. 


Diagrams. — In  order  to  give  a  clearer  idea  of  the  relation  between 
these  quantities,  viz.,  pressures,  volume,  and  energy,  we  plot  two 
curves  which  represent  the  volumes  or  the  energies  as  functions 
of  the  pressure.  Therefore  in  our  graphic  method  we  ha\'e  to  plot 
the  pressure  as  abscissae  and  the  volumes  or  the  energies  as  ordi- 
nates.  The  author  employed  the  leg  instead  of  the  arm  for  these 
determinations,  because  he  found  that  in  cases  of  hypertension 
disagreeable  sensations  and  even  pain  may  be  produced,  an  occur- 


190      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

rence  which  it  is  said  can  be  avoided  when  the  cuff  is  fastened 
around  the  calf  (Fig.  84). 

We  have  had  no  experience  with  Christen's  method.  The  author 
claims  that  the  results  obtained  by  it  when  applied  in  studying 
the  effect  of  work,  rest,  medication,  etc.,  are  satisfactory.  It  is 
essential  that  the  variations  of  the  summit — a  rise  or  a  fall,  a 


Fig.  85. — Christen's  energometer. 


shifting  to  a  higher  or  lower  level,  a  sharpening  or  flattening  of 
the  curve  (Fig.  84) — be  expresssed  in  absolute  values,  the  pressure 
gr- 


in 


cm. 


; ,  the  volume  in  cm.*  and  the  energy  in  gr.  cm.^ 


Extreme  care  in  technic  is  absolutely  essential.  The  readings 
must  be  taken  with  the  patient  as  well  as  the  patient's  arm  in  the 
same  position.  The  cuff  must  be  applied  to  exactly  the  same  region 
of  the  arm,  which  should  be  marked,  and  needless  to  say  the  same 
arm  must  be  used  for  successive  observations  (Dunkan).  Leg  read- 
ings are  inaccurate.  The  energy  of  the  pulse  wave  even  in  normal 
subjects  is  variable,  but  there  are  limits  which  are  not  normally 
exceeded.    Muscular  exercise,  and  cardiac  hypertrophy  with  good 

'  Christen's  energometer,  manufactured  by  Hausmann  Instrument  Company, 
St.  Gallen,  Switzerland. 


METHODS  OF  ESTIMATING   THE  RATE  OF  BLOOD  FLOW     191 

compensation  show  high  readings.  Adrenalin  injections  cause  high 
values  independently  of  any  effect  on  blood-pressure  (Drouven). 
The  Determination  of  Intra-abdominal  Pressure. — Blood-pressure 
may  be  considerably  influenced  by  intra-abdominal  pressure,  on 
which  account  it  is  sometimes  desirable  to  know  what  the  height 
of  the  latter  pressure  is.  This  may  be  determined  (1),  as  suggested 
by  Moritz,  by  introducing  into  the  stomach  a  tube  into  which  a 
thin  rubber  window  has  been  inserted,  the  tube  being  connected 
with  a  manometer.  (2)  By  means  of  a  special  instrument  devised 
by  Engelen^  which  consists  of  a  large  glass  bell,  the  bottom  of  which 
is  sealed  with  a  thin  rubber  dam.  The  latter  will  project  either 
inward  or  outward,  as  the  pressure  relations  on  either  side  of  the 
membrane  may  vary. 


Fig.  86. — Engelen's  instrument  for  the  determination  of  intra-abdominal  pressure. 

The  instrument  is  placed  upon  the  abdominal  wall,  connected 
with  a  manometer,  and  sufficient  air  is  pumped  into  the  bell  to 
equalize  the  pressure  on  each  side  of  the  membrane  in  the  interior 
of  the  bell  and  the  outer  abdominal  wall — this  being  shown  by  an 
indicator. 

Deep  inspiration  may  cause  a  pressure  of  —57  mm.  Hg.;  forced 
expiration,  +87  mm.  During  normal  parturition  a  pressure  of  40 
mm.  is  usual  which  with  dystocia  may  rise  as  high  as  +125  mm. 

(3)  Variations  in  abdominal  pressure  may  also  be  determined  by 
inserting  a  rubber  bag  (cylinder  in  casts  7  cm.  by  IG  cm.)  into  the 
rectum,  which  when  inflated  with  air  is  connected  with  a  ■Nlarey 
tambour.2    The  normal  intra-abdominal  pressure  is  above  that  of 


*  Ueber  Messung  u.  Bedeutung  des  Abdominaldruckes,  Deutsch.  mod.  Wchnschr., 
1911,  No.  19. 

2  Weber,  E. :  Ueber  eine  neue  Mcthode  zur  Untersuchung  dcr  Druckschwank- 
ungen  in  der  Bauch  Hohle,  Zentralbl.  f.  Physiol.,  Leipsic  u.  Wien,  1906,  xx,  329-336. 


192      FUNCTIONAL  EFFICIENCY  OF  THE  CIRCULATION 

the  atmospheric  pressure.  It  fluctuates  with  the  respiratory  excur- 
sions of  the  thorax  and  the  diaphragm.  Anything  which  dimin- 
ishes the  tone  of  these  structures  causes  a  lowering  of  abdominal 
pressure.  Distention  of  the  abdomen  by  fluid  or  gas  increases  the 
pressure  and  this  is  in  turn  followed  by  a  fall  of  blood-pressure  due 
to  a  diminished  venous  inflow,  and  consequently  a  decreased  left 
ventricular  systolic  output^  (see  page  44). 

1  Emerson,  H.:  Intra-abdominal  Pressure,  Arch.  Int.  Med.,  1911,  vii,  354. 


CHAPTER  VI. 

ARTERIAL  HYPOTENSION. 

ESSENTIAL  HYPOTENSION    (CONSTITUTIONAL  LOW 
ARTERIAL   PRESSURE). 

Arterial  hypotension,  by  which  we  understand  a  systoHc 
pressure  of  or  below  115  mm.  Hg.,  generally  in  association  with  a 
diastolic  pressure  below  80  mm.,  is  a  very  common  condition. 
Hypotension  may  occur  after  hemorrhage,  in  acute  infectious  dis- 
eases, in  conditions  of  malnutrition  or  cachexia,  such  as  tubercu- 
losis, carcinoma,  Addison's  disease.  It  may  also  occur  in  anemia, 
in  paresis,  in  osteo-arthritis,  in  cardiac  dilatation,  tachycardia  and 
in  cardiac  decompensation.  Hypotension  is  also  noted  in  associa- 
tion with  abnormalities  of  the  endocrine  functions  of  the  male 
gonads,  and  in  certain  individuals  who,  although  apparently  healthy 
are  not  robust,  in  whom  it  appears  as  part  of  their  constitutional 
make  up.  Two  renal  conditions — cyclic  and  orthostatic  albumin- 
uria, and  amyloid  disease  of  the  kidney  are  often  associated  with 
low  blood-pressure.  It  may  also  occur  as  a  result  of  intoxication — 
anaphylaxis,  nicotinism,  alcoholism.  Hypotension  also  occurs  in 
surgical  shock;  as  a  result  of  some  forms  of  anesthesia,  especially 
that  of  chloroform,  and  as  a  terminal  event  during  the  last  ebbing 
tide  of  life. 

Relative  hypotension  often  follows  hypertension  when  vascular 
and  cardiac  resources  are  overtaxed. 

Ssnnptomatology. — Essential  hypotension  is  a  very  common  con- 
dition, the  importance  of  which  has  been  signally  emphasized  by 
L.  F.  Bishop.  Many  apparently  healthy  individuals,  although  not 
robust,  often  in  youth  and  early  adult  life  normally  have  a  systolic 
and  a  diastolic  blood-pressure  ranging  between  115  and  100,  and 
between  80  and  70  mm.  respectively.  Such  individuals  lack  stamina, 
tire  easily,  complain  of  cold  extremities  and  of  the  inability 
to  do  prolonged  mental  or  physical  work.  They  often  suffer 
from  dyspepsia,  which  upon  investigation  proves  to  be  of  the 
"nervous"  variety,  not  infrequently  due  to  hypomotility  and  super- 
imposed on  an  anatomical  background  of  partial  or  total  splanch- 
13 


194  ARTERIAL  HYPOTENSION 

noptosis.  They  are  not  actually  ill,  yet  they  are  rarely  well;  they 
complain  of  all  sorts  of  symptoms,  headache,  lassitude,  mental 
depression,  "gouty"  pains,  constipation,  etc.  Their  bodily  temper- 
ature is  generally  subnormal  iji  the  morning  and  they  suffer  from 
cold  extremities  due  to  a  sluggish  peripheral  circulation.  They  are 
apt  to  be  filed  away  in  that  much  overloaded  diagnostic  pigeon- 
hole labeled  "neurasthenia."  They  are  often  of  the  high-strung 
nervous  temperament,  "go  on  their  nerves,"  are  moody  and  emo- 
tional, and  sensitive  to  caffein  and  nicotine,  as  well  as  to  atmos- 
pheric and  barometric  fluctuations.  Staehelin^  found  that  a  fall  of 
barometric  pressure  produces  a  lowering  of  the  arterial  tension  in 
many  individuals.  In  extreme  cases  they  often  fall  asleep  when 
sitting  upright  and  suffer  from  insomnia  when  they  go  to  bed. 
Perhaps  enough  has  been  said  to  illustrate  the  picture,  although 
pages  might  be  written  upon  the  symptomatology^ 

The  inability  of  the  subjects  of  constitutional  hypotension  to 
stand  the  demands  of  prolonged  physical  exertion  is  the  direct 
result  of  their  low  blood-pressure.  Recent  experimental  evidence 
has  shown  that  an  increased  arterial  pressure  such  as  occurs  nor- 
mally during  exercise  increases  the  height  of  muscular  contraction 
when  the  pressure  is  below  a  certain  critical  level,  whereas  a 
decreased  pressure  below  this  point  has  the  opposite  effect.  An 
increased  flow  flushes  out  and  neutralizes  the  fatigue  products.^ 

Observations  over  a  period  of  two  years  in  a  case  of  constitutional 
low  tension  by  Edgecombe^  showed  that  pressure  was  higher  in 
the  evenings  than  in  the  mornings.  No  relationship  could  be  estab- 
lished between  pressure  and  pulse  rate.  Exercise,  mental  effort, 
grief,  altitude,  tea,  coffee,  and  tobacco  had  a  pressure-increasing 
effect.  Constipation  lowered  the  tension.  Therapeutically,  caffein 
and  pituitary  substance  raised,  whereas  alcohol  lowered  the  pressure. 
Strychnin,  digitalis,  calcium,  and  glycogen  were  without  effect. 

While  it  is  unsafe  to  generalize  from  a  single  ca?e,  the  results 
reported  correspond  quite  closely  to  what  is  usually  observed  in 
this  class  of  cases. 

Patients  with  essential  hypotension  not  only  have  an  habitually 
low  blood-pressure,  but  their  response  to  different  stimuli  which 
normally  afi'ect  blood-pressure  either  locally  or  generally  is  either 
quantitatively  or  qualitatively  abnormal.    The  effect  of  a  change 

•  Ueber  d.  Einfluss  d.  taglichen  Luftdruckschwankungen  auf  den  Blutdruck,  Med. 
Klinik,  1913,  ix,  862. 

2  Gruber,  C.  M.:   Studies  in  Fatigue,  Am.  Jour.  Physiol.,  1913,  xxxii,  221. 
'  Royal  Soc.  Med.,  Med.  Sect.,  February  28,  1911. 


ESSENTIAL  HYPOTENSION  195 

of  posture  from  the  recumbent  to  the  erect  position  is  normally  a 
variable  one,  but  the  maximum  and  minimum  pressures  invariably 
approach  each  other  (Erlanger).  The  pulse  rate  decreases,  the 
pulse-pressure  falls.  These  changes  are  due  to  the  effect  of  gravity. 
The  pressure  in  the  femoral  artery  is  higher  than  that  in  the  carotid 
in  proportion  to  the  difference  of  the  hydrostatic  pressure  of  the 
column  of  blood  which  separates  the  two  points  of  measurement. 

Difference  in  height  of 
column  separating 
Posture.  Brachial.  Tibial.  Difference.  armlets. 

Horizontal      ...  140  138  2  0 

Standing         ...  136  204  68  68.5 

L.  post.,  legs  up  .      .  122  76  46.  46.1 

Vertical,  head  down  .  148  70  78  77.7 

If  normal  postural  change  in  pulse  rate  (G  to  10  beats)  does  not 
occur,  it  shows  too  much;  if  exaggerated,  too  little  splanchnic 
tone.  If  the  response  is  reversed  there  is  apt  to  be  extensive  dis- 
ease of  the  cardiovascular  system — generally  hypertension.  In 
healthy  individuals  the  transition  from  the  recumbent  to  the  erect 
posture  generally  produces  a  slight  fall  of  the  systolic  and  a  rise 
of  diastolic  pressure,  thus  a  diminution  of  pulse-pressure.  In  people 
with  relaxed  abdominal  walls  and  enteroptosis  a  marked  falling 
of  the  systolic  pressure  (25  mm.)  and  a  slight  lowering  of  the 
diastolic  pressure  have  been  noted. ^  (See  Crampton's  test,  p.  152.) 
A  lowered  splanchnic  tone  leads  to  more  or  less  cerebral  anemia, 
and  a  sudden  assumption  of  the  erect  posture  when  the  individual 
has  been  recumbent  or  stooping  to  the  ground  with  the  knees 
flexed  often  causes  a  temporary  vertigo.  Syncopal  attacks  from 
relatively  insufficient  causes  are  in  case  of  the  female  sex,  at  least, 
by  no  means  rare.  An  engorged  condition  of  the  viscera  is  often 
evident  on  inspection  during  abdominal  operations.  The  vascular 
supply  especially  in  the  veins  is  excessive.  Ptosis  of  the  right 
kidney  not  only  tends  to  constrict  its  own  vascular  supply,  but  by 
dragging  upon  the  inferior  vena  cava  and  the  aorta  may  seriously 
disturb  the  lumen  of  these  vessels,  contributing  in  no  small  measure 
to  vascular  stasis.-  These  results  are  noted  clinically  by  the  large 
gush  of  urine  which  often  follows  a  short  period  of  recumbency. 
(See  Arterial  Functionation,  p.  180.) 

Another  frequent  symptom  resulting  from  low  blood-pressure  is 

'  Birtch,  Fayette  W.,  and  Inman,  Thomas  G.:  Blood-pressure  Observations  on 
Patients  with  Relaxed  Abdominal  Musculature,  Jour.  Am.  Med.  Assn.,  1912,  Iviii, 
S.   265-268. 

'  Mackenzie,  K.  A.  J.:  The  Role  of  Movable  Kidney  in  Intestinal  and  Vascular 
Stasis,  Jour.  Am.  Med.  Assn.,  1912,  lix,  338, 


196  ARTERIAL  HYPOTENSION 

hejidache,  relief  from  which  is  too  often  sought  in  headache  pow- 
ders, which  of  course  eventually  aggravate  the  condition.  Eleva- 
tion of  blood-pressure  is  followed  by  improvement. 

Etiology. — "In  the  upright  posture  the  blood  tends  to  settle 
in  the  capacious  channels  of  the  splanchnic  vascular  bed.  The 
'head-up'  position  in  four-footed  animals  may  lead  to  extraordinary 
lowering  of  blood-pressure  in  the  carotid  arteries  and  presumably 
to  critical  anemia  of  the  brain.  But  in  man  there  has  been  devel- 
oped a  compensatory  reaction,  undoubtedly  chiefly  vasomotor,  by 
means  of  which  the  vessels  of  the  dependent  parts  of  the  body, 
probably  the  arteries  of  the  splanchnic  area,  contract  under  stimulus 
of  the  upright  posture  and  maintain  a  fairly  uniform  distribution 
of  the  blood  mass. 

"The  splanchnic  and  the  systemic  veins  are  capable,  when  dilated, 
of  containing  a  large  proportion  of  the  total  volume  of  the  blood. 
Under  exercise  the  blood  which  is  in  excess  of  the  amount  which  the 
heart  can  handle,  is  stored  in  the  systemic  veins.  During  rest  this 
blood  is  again  reservoired  in  the  splanchnic  veins.  The  normal 
give  and  take  balance  between  these  two  storage  depots  may  be 
upset.  In  the  hypotensive  cases  the  splanchnic  vessels  remain  over- 
loaded, too  little  blood  reaches  the  heart,  the  systolic  output  is 
small  and  arterial  tension  low.  The  opposite  condition  obtains  in 
arterial  hypertension.^     (See  Abdominal  Pressure.)  , 

"No  physiological  coordination  can  be  conceived  that  is  more 
important  than  this  to  the  welfare  of  the  organism  as  a  whole. 
It  is  to  be  expected,  therefore,  on  a  priori  grounds,  that  minor 
compensations  having  the  same  general  purpose  should  here  and 
there  disclose  themselves.  When  the  radial  pulse  fails  in  awTist 
which  is  raised  above  the  level  of  the  head,  the  result  may  be  due 
either  to  passive  drainage  of  the  blood  from  the  artery,  followed 
by  a  purely  local  contraction  of  the  arterial  wall,  or  to  active  vaso- 
motor contraction  of  the  vessel  under  the  stimulus  of  gravity.  As 
touching  the  former  view,  Bayliss  has  shown  that  peripheral 
arteries  freed  from  their  nervous  connections  respond  to  variations 
of  internal  pressure  by  contracting  as  the  pressure  rises  and  dilating 
as  it  falls.  Sifting  the  great  number  of  observations  bearing  on 
this  subject,  the  latter  explanation  seems  to  be  the  only  possible 
one.  In  other  words,  according  to  this  view  pulse  failure  in  the 
elevated  radial  artery  is  a  sign  of  vasomotor  activity  and  belongs 
to  the  series  of  physiological  compensations.    It  is  comprehensible 

>  Hill,  Leonard:  Influence  of  the  Force  of  Gravity  on  the  Circulation  of  the  Blood, 
Jour.  Physiol.,  1895,  xviii,  15. 


ESSENTIAL  HYPOTENSION  197 

as  such,  if  we  presume  that  contraction  of  the  radial  arteries  helps 
to  maintain  blood-pressure  in  more  vital  tissues  by  diverting  the 
blood  stream  from  less  sensitive  organs.  It  has  often  been  observed 
that  pulse  failure  which  is  obvious  in  the  elevated  wrist  at  the 
beginning  of  a  series  of  observations  is  not  evident  later  on.  That 
is,  the  pulse  failure  mechanism  seems  subject  to  fatigue.  Excite- 
ment or  emotion  which  increases  the  total  outflow  of  nerve  energy 
tends  to  inhibit  the  pulse  failure.  In  general,  in  perfectly  normal 
individuals  who  are  in  vigorous  physical  condition,  the  radial  pulse 
is  maintained  when  the  arms  are  raised.  In  the  same  class  of  per- 
sons, when  more  or  less  debilitated  by  confining  occupations  or 
subnutrition,  the  pulse  often  fails.  In  an  acute  febrile  disorder  the 
pulse  usually  remains  when  the  arms  are  raised;  during  convales- 
cence, especially  with  the  establishment  of  compensation  in  cardiac 
disease,  the  pulse  often  fails.  Numerous  observations  seem  to  show 
that  these  differences  in  the  reaction  of  the  pulse  do  not  depend  on 
the  amount  of  blood  volume  or  the  degree  of  maximal  arterial 
pressure.  It  is  not  only  conceivable,  but  probable,  that  signs  of 
physiological  compensation  which  are  absent  during  robust  health 
or  active  disease  should  become  manifest  when  the  normal  vital 
energy  is  reduced  or  when,  as  a. result  of  disease,  the  efforts  of 
physiological  adjustment  must  become  more  strenuous  to  maintain 
the  needful  outflow  and  normal  distribution  of  the  blood  mass. 
The  older  writers  in  this  field  were  prone  to  attribute  the  pulsus 
paradoxus  to  mechanical  interference  with  the  normal  blood  flow, 
basing  their  position  on  the  frequency  with  which  the  phenomenon 
attends  pathological  adliesions  between  the  mediastinal  tissues. 
The  facts  that  have  been  rehearsed  seem  to  indicate  that  mechanical 
abnormalities  within  the  chest  may  only  indirectly  cause  pulse 
failure,  by  exaggerating  certain  reflexes  which  under  perfectly 
normal  conditions  are  masked. 

"As  already  stated,  failure  of  the  elevated  pulse  does  not  seem 
to  occur  in  persons  showing  signs  of  general  arteriosclerosis.  The 
thought  may  not  be  far  amiss  that  this  constant  organic  tendency 
of  later  life  may  in  itself  be  a  compensation  which,  by  diminishing 
the  distensibility  of  the  vessels  under  the  hydrostatic  pressure  of 
the  blood,  may  more  or  less  substitute  that  constant  and  necessary 
redistribution  of  the  blood  mass  which  has  become  impossible  to 
a  senile  vasomotor  apparatus"  (L.  Hill). 

Goldthwaite^  classifies  the  essential  hypotensive  individual  as 

'  Shattuck  Lecture,  An  Anatomical  and  Mechanistic  Conception  of  Disease, 
Boston  Med.  and  Surg.  Jour.,  1915,  clxxii,  881. 


198  ARTERIAL  HYPOTENSION 

the  "carnivorous  type"  of  man  and  suggests  that  the  low  blood- 
pressure,  weak  pulse,  subnormal  matutinal  temperature,  etc.,  are 
due  to  mechanical  causes.  According  to  this  conception  the  absence 
of  retroperitoneal  fat  exposes  tlje  sympathetic  ganglia  and  the  large 
bloodvessels  which  lie  unprotected  on  the  anterior  surface  of  the 
spine,  to  irritation  and  pressure  except  when  the  individual  lies  on 
his  face  or  his  side.  This  perhaps  also  applies  to  the  adrenals.  A 
long  mesentery  by  dragging  downward  in  the  erect  posture  favors 
splanchnic  stasis;  and  the  low  diaphragm  with  its  small  respiratory 
excursion  does  not  efficiently  aid  the  propulsion  of  blood  from  the 
abdominal  to  the  thoracic  cavity.  While  these  anatomical  factors 
perhaps  cannot  alone  account  for  the  symptoms,  they  are  quite 
sufficient  to  do  so  when  we  add  the  faulty  standing  and  sitting 
postures  which  are  habitually  assumed  by  individuals  of  this  type. 

The  most  constant  finding  in  the  class  of  individuals  under  consid- 
eration is  arterial  hypotension.  They  often  have  varying  degrees 
of  gastroptosis  but  so  do  many  apparently  healthy  people  whose 
blood-pressure  is  normal  and  who  have  no  gastric  symptoms  so 
long  as  their  nerve  tone  is  up  to  par.  It  would  seem,  therefore,  that 
the  splanchnoptosis  is  not  the  underlying  causative  factor,  although 
it  unquestionably  acts  an  important  part  in  some  cases.  We 
further  ask  ourselves  whether  the  hypotension  is  the  cause  of  the 
nervous  manifestations  or  whether  a  lack  of  proper  nervous  stimuli 
is  the  cause  of  the  hypotension?  This  question  cannot  be  posi- 
tively answered.  Undoubtedly  there  is  a  complex  interaction  of 
these  causes  by  virtue  of  which  the  one  may  deleteriously  affect 
the  other,  from  which  we  could  readily  construct  a  beautiful  and 
typical  example  of  the  "vicious  circle"  did  it  seem  worth  while  to 
do  so. 

Chronic  low  arterial  pressure  has  also  been  attributed  to  toxemia, 
and  cholin  salts  have  been  suggested  as  the  active  substance.^  It 
has  been  claimed  by  Popielski  and  Modrokowski  that  chemically 
pure  cholin  would  produce  a  rise,  not  a  fall  of  pressure,  but  Mendel, 
Underhill  and  Renshaw-  have  shown  that  the  injection  of  chemi- 
cally pure  cholin  did  produce  a  short  fall  of  pressure. 

Histamin  may  be  formed  in  the  intestinal  tract  by  the  action  of 
the  Bacillus  aminophylus  intestinalis  upon  the  amino-acids.  This 
substance  is  said  to  lower  blood-pressure  and  has  been  accredited 
with  an  etiological  role  in  some  cases  of  arterial  hypotension. 

Functional  or  constitutional  physiological  vasomotor  unfitness, 

'  Morel,  Albert:  Recherches  sur  rorigiiic  cliniquc  do  rhypotension,  Livre  jubilaire 
du  Pr.  Teissier,  Lyon,  1010. 

2  Aetioii  of  Salts  of  Cholin  on  Arterial  Blood-prossurc,  Jour.  Phar.  and  Exj). 
Therap.,    1912,   iii,   649. 


ORTHOSTATIC  ALBUMINURIA  199 

owing  mainly  to  improper  nerve  balance,  seems  to  be  the  most 
satisfactory  explanation  for  the  majority  of  cases  of  afebrile  hypo- 
tension. 

Test  for  Splanchnic  Stasis. — The  degree  of  splanchnic  venous 
stasis  may  be  estimated,  as  suggested  by  Oliver,  by  placing  a  28- 
pound  bag  of  shot  uniformly  across  the  abdomen  in  a  recumbent 
subject. 

1.  In  the  ear'ly  morning  before  food  has  been  taken,  no  blood- 
pressure  changes  are  observed  in  normal  subjects. 

2.  Thirty  minutes  after  a  meal,  blood-pressure  rises  17  to  20 
mm.  Hg.    A  rise  of  18  mm.  is  considered  normal. 

3.  After  vigorous  exercise  the  shot  bag  causes  no  rise  of  pressure, 
but  when  the  subject  is  exhausted  from  exercise  a  rise  of  pressure 
can  be  demonstrated. 

If  blood-pressure,  especially  systolic  pressure,  is  higher  in  recum- 
bency than  in  the  sitting  posture,  vasomotor  weakness  of  the 
splanchnics,  either  with  or  without  loss  of  abdominal  muscular 
tone,  may  be  assumed  (Sewall). 

ORTHOSTATIC   ALBUMINURIA. 

In  health  the  assumption  of  the  erect  posture  produces  an 
increased  urinary  flow,  and  a  relatively  increased  sodium  chloride 
output.  In  the  subjects  of  circulatory  disease  the  conditions  are 
reversed.  In  orthostatic  albuminuria  there  is  a  qualitative  change 
which  points  to  a  less  efficient  renal  circulation  in  the  standing 
posture.^ 

Numerous  observers  have  commented  upon  the  frequent  asso- 
ciation of  orthostatic  albuminuria  and  cardiovascular  weakness. 
This  form  of  albuminuria  is  often  associated  with  arterial  hypo- 
tension. The  thought  naturally  suggests  itself  that  the  albuminuria 
is  brought  about  by  the  fact  that  the  splanchnic  vasomotor  appa- 
ratus only  insufficiently  compensates  the  blood-pressure  changes 
induced  by  a  change  of  posture,  thus  leading  to  vascular  changes  in 
the  kidney  and  the  albuminuria  while  the  patient  is  erect.^  The 
exact  nature  and  mechanism  of  these  vascular  changes  is  still  in 
doubt.  Renal  anemia  or  venous  congestion,  eitlier  as  the  result  of 
increased  intra-abdominal  pressure  or  from  kinking  of  the  vessels 
in  a  more  or  less  movable  kidney,  have  been  suggested. 

1  Loeb,  H.:  Klin.  Untersuch.  u.  d.  Einfluss  von  Kreislaufsaenderungen  auf  d. 
Urinzusammensetzung,  Deutsch.  Arch.  f.  klin.  Med.,  1905,  Ixxxiv,  579. 

2  Miintzer,  E.:  Zur  Lehre  v.  d.  vaskuliireii  Hypotonien,  Wicn.  klin.  Wchnschr., 
1910,  xxiii.  1341. 


200  ARTERIAL  HYPOTENSION 

Neither  of  these  explanations  is  universally  applicable.  The 
kidneys  are  by  no  means  always  movable,  and  increase  of  intra- 
abdominal pressure  on  standing  occurs  in  normal  individuals. 
Further,  why  should  the  albuminuria  only  appear  on  rising  in  the 
morning  and  not  in  the  afternoon?  According  to  Forges  and 
Fribram,^  the  cause  lies  in  a  spastic  contraction  of  the  renal  arteries. 

This  type  of  albuminuria  is  sometimes  seen  in  convalescence, 
either  from  fevers  or  from  trauma,'  which  has  necessitated  a  long 
stay  in  bed,  under  which  conditions  the  vasomotor  response  to 
changes  of  posture  are  soon  lost,  so  that  the  individual  on  assuming 
the  erect  posture  promptly  becomes  w^eak  and  dizzy. 

Hooker  found  that  with  a  constant  mean  pressure  the  rate  of 
blood  flow  and  of  urinary  secretion  bear  a  direct  relation  to  the 
pulse-pressure,  whereas  the  albumin  secreted  by  the  kidney  varied 
inversely,  experimental  evidence  which  is  in  accord  with  the  findings 
of  Erlanger  and  Hooker  in  two  cases  of  orthostatic  albuminuria.^ 
Recent  researches  of  Bass  and  Wessler^  have,  however,  contro- 
verted a  number  of  the  previously  described  results.  They  found 
that  blood-pressures  in  children  suffering  from  orthostatic  albumin- 
uria differ  but  little  from  normal  findings. 

"Functional"  albuminuria  is  not  infrequently  met  with  at  the 
period  of  adolescence,  often  in  association  with  anemia  and  low 
blood-pressure.  Dukes,  who  has  observed  many  of  these  cases 
classifies  them  in  three  categories. 

1.  Cases  with  cold  extremities,  clammy  hands,  low  blood-pressure, 
and  deficient  vasomotor  reactions,  as  shown  by  syncopal  attacks, 
and  by  a  fall  of  blood-pressure  upon  rising  from  a  reclining  to  an 
erect  posture. 

2.  Cases  with  very  labile  but  generally  high  blood-pressures. 
This  is  the  commonest  type. 

3.  Cases  occurring  in  spare,  neurotic,  high-strung  and  generally 
hyperesthetic  individuals. 

It  is  of  course  w^ell  known  that  posture  may  affect  albuminuria 
even  in  organic  cases,  especially  those  associated  with  cardiac 
insufficiency. 

The  significance  of  alhnminuria  may  often  be  more  correctly 
interpreted  by  means  of  blood-pressure  observations.  This  symp- 
tom may  occur  in  perfectly  healthy  young  men  after  forcible  exer- 
cise.   In  association  with  slight  hematuria  it  is  especially  frequent 

1  Zur  Kentniss  d.  orthostatischen  Albuminurie,  Deutsch.  Arch.  f.  klin.  Med., 
1907,  xc,  367. 

'Jour.  Phj-siol.,  November  1,  1910. 

'  Blood-pressure  in  Children  Showing  Orthostatic  Albuminuria,  Arch.  Int.  Med., 
1913,  xiii,  39. 


ARTHRITIC  AND  RHEUMATOID  CONDITIONS  201 

after  boxing  bouts,  in  which  "kidney  blows"  abet  its  appearance 
(Stanton).  The  occurrence  of  albuminuria  after  strenuous  exercise 
is  generally  attributed  to  a  secondary  splanchnic  vasodilatation 
which  follows  the  primary  vasoconstriction,  and  which  produces  a 
temporary  renal  congestion.  Lee^  in  examining  662  apparently 
healthy  students  found  albuminuria  in  5  per  cent.  In  some  the  con- 
dition was  transient,  in  some  orthostatic  and  in  others  permanent. 
Eight  showed  a  systolic  pressure  over  140  mm.  Hg.,  yet  only  one 
case  was  regarded  as  nephritic  and  this  case  differed  from  the 
others  in  having  an  increased  diastolic  pressure  (100 +). 

Paroxysmal  hemoglobinuria  and  hematuria  have  also  been  attrib- 
uted to  loss  of  vasomotor  equilibrium.  The  latter  is  generally  asso- 
ciated with  low  blood-pressure.  Hemoglobinuria  is  sometimes 
brought  on  by  walking,  especially  if  this  is  done  in  a  lordotic  pos- 
ture. This  type  of  hemoglobinuria  has  been  explained  as  resulting 
from  vasomotor  instability  causing  an  abnormal  circulatory  state 
in  the  spleen.^ 

ARTHRITIC   AND   RHEUMATOID    CONDITIONS. 

Excluding  lesions  of  a  true  gouty  nature  which  are  usually 
associated  with  hypertension,  there  is  a  large  group  of  so-called 
"rheumatic"  ailments  whose  pathogenesis  is  still  unknown,  which 
often  occurs  in  hypotensive  individuals  and  which  tends  to  disap- 
pear when,  as  the  result  of  a  more  efficient  circulation,  better  nutri- 
tion of  the  muscles,  joints  and  fibrous  structures  has  been  obtained. 
To  this  class  belong  certain  cases  of  lumbago,  sciatica,  neuritis, 
stiff  neck,  and  "myalgia."  Rheumatoid  arthritis  and  "phospha- 
turia"  also  generally  occur  in  association  with  low  arterial  pressure. 

Low  blood-pressure  is  also  met  with  in  cases  of  status  lymphaticus 
in  which  condition,  according  to  WieseP  and  Hedinger,^  it  is  asso- 
ciated with  hypoplasia  of  the  chromaffin  system. 

Treatment  of  Essential  Hypotension.^ — The  curative  results  of 
therapy  in  arterial  hypotension  are  never  brilliant  and  often  dis- 
appointing, and  yet  in  the  majority  of  cases,  especially  if  the  sub- 
ject be  not  too  far  advanced  in  life,  much  can  be  accomplished. 
The  trouble  lies  in  the  fact  that  we  are  combating  an  inbred  consti- 
tutional weakness  and  that  an  arrest  of  symptoms  often  only  lasts 
as  long  as  the  treatment  is  continued. 

1  Lee,  R.  I.:  Blood-pressure  Determinations,  Urinary  Findings  and  Differential 
Blood  Counts  in  a  Group  of  662  Young  Male  Adults,  Boston  Med.  and  Surg.,  Jour., 
1915,  dxxiii,  541. 

*  Forges  and  Strisower:     Deutsch.  Arch.  f.  klin.  Med.,  January  7,  1915,  No.  2. 

*  Zur  Path.  d.  chromaffinen  System,  Virchows  Arch.,  1904,  vol.  clxxvi. 

*Ueber  d.  Kombination  von  Morbus  Addisonii  mit  Status  Lymphaticus,  Frank- 
furter Ztschr.  f.  Path.,  1907,  i,  527. 


202  ARTERIAL  HYPOTENSION 

The  treatment  consists  mainly  in  a  proper  regulation  of  the 
patient's  daily  life,  the  details  of  which  must  be  supervised  with 
the  idea  of  diminishing  the  factors  which  lead  to  a  lowered  nerve 
tone.  That  mental  overwork  is  often  largely  contributory  in 
increasing  hypotension  is  corroborated  by  Bonser's'  studies,  which 
showed  that  intellectual  fatigue  among  twelve  students  observed 
was  capable  of  diminishing  vasomotor  reactions  to  emotional  stimu- 
lation. A  complete  rest  cure  in  extreme  cases  may  be  advisable 
at  the  beginning.  After  this  a  general  routine  mode  of  life  as  is 
generally  advised  for  neurasthenic  patients  is  in  order.  A  few 
points,  however,  deserve  to  be  emphasized:  (1)  Requisite  rest  and 
sleep  (an  eight-hour  allowance  of  the  latter  being  a  minimum). 
(2)  Relaxation — the  avoidance  of  too  prolonged  mental  or  physical 
work.  The  necessity  of  a  small  but  regular  amount  of  physical 
exercise,  preferably  outdoor.  (3)  The  avoidance  of  excesses — diet- 
ary or  sexual.  (4)  Tobacco — these  patients  are  very  sensitive  to 
tobacco,  an  excessive  use  of  which  is  often  directly  accountable 
for  their  symptoms. 

Hydrotherapy. — Aside  from  the  foregoing,  hydrotherapy  is  by 
far  the  most  successful  method  of  treatment.  The  Nauheim  bath, 
the  Vichy  douche^  or  the  needle  bath  may  be  recommended,  but 
almost  equally  good  results  may  be  obtained  with  the  ordinary 
home  shower  bath. 

The  patient  is  instructed  to  take  a  hot  tub  bath  each  morning 
on  rising,  practising  active  autofriction  with  rough  linen  tape  wash 
rags  or  mittens.  When  thorouglily  w^armed  he  is  to  turn  on  the 
cold  shower,  this  to  be  followed  by  active  friction  with  a  rough 
towel.  The  length  of  the  stay  under  the  cold  spray  is  to  be  gradu- 
ally increased  and  after  a  short  trial  will  be  attended  by  a  good 
vigorous  reaction,  the  skin  becoming  pink  and  accompanied  by  a 
pleasant  tingling  glow.  This  treatment  must  be  kept  up  indefi- 
nitely. Where  no  shower  bath  is  available,  cold  water  may  be 
poured  over  the  head  and  shoulders  from  pitchers. 

In  patients  with  enteroptosis  and  with  relaxed  abdominal  muscles 
sys;tematic  exercises,  calculated  to  restore  muscular  tone,  or  some 
form  of  abdominal  support,  are  of  distinct  utility.  Massage  is  also 
beneficial. 

Goodman^  has  emphasized  the  importance  of  daily  morning 
calisthenics,  especially  those  which  tend  to  compress  the  abdom- 

1  Psych.  Rev.,  March,  1903. 

*  The  Vichy  douche  consists  of  a  needle  douche  projected  downward  on  the  patient 
throughout  the  duration  of  the  bath,  while  general  massage  is  administered  by  an 
attendant. 

'  Some  Cases  of  Arterial  Hypotension  Associated  with  a  Definite  Symptomatology, 
Am.  Jour.  Med.  Sc,  1914,  cxlvii,  503. 


ARTHRITIC  AND  RHEUMATOID  CONDITIONS  203 

inal  viscera,  increase  respiratory  excursion  and  strengthen  the 
muscles  which  maintain  a  correct  standing  posture.  Such  exercises 
must  not  be  carried  to  the  point  of  breathlessness,  much  less  exhaus- 
tion, but  should  be  gradually  increased  in  severity  and  duration  as 
the  individual  is  trained  up  to  his  task. 

Drugs. — Strychnin  as  an  adjuvant  to  increase  nerve  tone  is  the 
most  generally  useful  drug,  though  it  has  no  direct  effect  on  blood- 
pressure.  Digitalis  is  useless  unless  there  be  a  definite  cardiac 
lesion. 

Although  we  possess  numerous  drugs  which  may  be  used  to  lower 
blood-pressure,  few  if  any  fulfil  the  purpose  of  raising  blood-pressure. 
Watson^  found  that  atropin,  camphor,  cotarnin,  digitoxin  and 
strychnin  were  valueless  for  this  purpose.  Physostigmin,  which 
may  raise  pressure,  cannot  be  used  in  adequate  dosage  on  account 
of  nausea  and  vomiting.  Tyraviin  (said  to  be  the  most  important 
active  constituent  of  the  watery  extracts  of  ergot)  gave  better 
results.  Musser,  Jr.,  has  reported  good  results  following  the 
administration  of  pituitrin  (see  p.  352), 

The  Termination  of  Essential  Hypotension. — The  ultimate  outcome 
of  cases  of  essential  hypotension  has,  so  far  as  we  are  aware,  not 
been  studied.  Individuals  belonging  to  this  class  are  of  necessity 
seriously  handicapped  in  their  career.  They  cannot,  as  a  rule, 
lead  the  strenuous  life  which  seems,  in  this  country  at  least,  to  be 
fast  becoming  the  "normal."  But  whether  this  enforced  modera- 
tion leads  to  a  longer  life,  with  a  diminished  tendency  toward  the 
development  of  arteriosclerotic  changes,  is  an  interesting  question. 
If  our  interpretation  of  the  pathology  of  this  condition  is  correct 
the  splanchnic  vessels  are  habitually  relaxed  and  overloaded  with 
blood.  Does  such  a  condition  predispose  to  vascular  disease  of  the 
intra-abdominal  vessels  and  organs,  or  does  the  passive  overloading 
with  venous  stasis  exert  a  less  deleterious  effect  upon  the  vascular 
wall  than  an  active  distention  due  to  a  powerful  heart  and  a  high 
vascular  tonus?  Do  these  individuals  later  in  life  develop  arterial 
hypertension  as  the  result  of  splanchnic  arteriosclerosis  with  its 
attendant  dangers  and  discomfitures,  or  does  Nature  mitigate  these 
tendencies  as  a  compensation  for  earlier  disabilities?  These  ques- 
tions must  await  further  studies  before  an  answer  can  be  given. 
The  case  of  the  puny  dyspeptic  "weakling"  who  weathers  the  storm 
of  an  acute  infection  to  which  the  robust  "full-blooded"  athlete 
succumbs  is  well  kno^\^l,  as  is  also  the  lanky  dyspeptic  who  outlives 
his  plethoric  friends.    "Causa  latet,  res  ipse  notissima.'' 

•  The  Value  of  Drugs  as  Blood-pressure  Elevators,  Practitioner,  1915,  xciv-,  No.  4. 


CHAPTER  VII. 
BLOOD-PRESSURE  IN  ACUTE  INFECTIOUS  DISEASE. 

Practically  all  febrile  infections  are  accompanied  by  a  fall  of 
blood-pressure,  although  in  some,  this  feature  is  specially  marked. 
The  personal  equation  of  the  patient  of  course  greatly  influences 
the  result.  In  the  so-called  sthenic  fevers  blood-pressure  is  not 
much  affected.  In  asthenic  fevers  the  fall  is  very  pronounced. 
Many  of  the  ill  effects  of  fever  are  directly  due  to  low  arterial 
pressure  and  it  is  now  generally  admitted  that  death  in  many 
infections,  is  quite  as  much  due  to  vasomotor  as  to  cardiac  failure. 
A  few  microbic  toxins  (Staphylococcus,  pyocyaneus,  mallein)  seem 
to  have  hypertensive  qualities  (Bosc  and  Vedel). 

Broadly  speaking,  the  extent  of  pressure  fall  tends  to  vary 
directly  with  the  fever,  but  there  are  many  exceptions  to  this  rule, 
for  the  reason  that  the  pressure  is  influenced  more  by  the  toxemia 
than  by  the  pyrexia.  In  severe  infections  with  a  weakening  circula- 
tion the  systolic  pressure  falls  and  pulse-pressiire  decreases.  A  well- 
sustained  pulse-pressure  is  to  be  construed  as  a  favorable  sign. 

Degeneration  of  the  adrenal  glands  in  infections,  especially 
diphtheria,  and  the  experimental  production  of  similar  lesions  by 
toxin  injections  have  led  some  authors  to  recommend  adrenalin 
as  a  therapeutic  medium,  both  on  account  of  its  effect  in  raising 
blood-pressure,  and  on  account  of  an  hypothetical  protective  power 
in  the  defense  of  the  organism. 

In  11  cases  of  infectious  disease,  Marx^  found  no  lack  of  epineph- 
rin  in  the  blood,  nor  was  the  blood-pressure  especially  low.  The 
amount  of  epinephrin  recoverable  from  the  suprarenal  glands  after 
death  bears  no  relation  to  the  character  of  the  fatal  disease.  The 
height  of  blood-pressure  bears  no  relation  to  the  epinephrin  con- 
tent of  the  glands.  The  variable  results  are  perhaps  due  to  the 
gradual  death  of  different  sets  of  the  glandular  cells.  It  seems 
likely,  therefore,  that  the  beneficial  effect  of  epinephrin  in  shock 
and  allied  states  is  due  to  its  vasoconstrictor  action.  It  is  therefore 
merely  a  symptomatic  and  not  a  specific  means  of  therapeusis. 

'  Ueber  den  Adrenalingehalt  der  Nebenniere,  Med.  Klinik  d.  Stadt.  Krankenanst., 
Mannheim,  Dissert.  Heidelberg,  1912,  vol.  xxiv. 


BLOOD-PRESSURE  IN  ACUTE  INFECTIOUS  DISEASE       205 

Elliot/  on  the  other  hand,  found  that  the  store  of  epinephrin  in 
the  adrenal  glands  is  diminished  by  fright,  anesthesia,  cerebral 
injury  and  bacterial  intoxications.  The  residual  epinephrin  has 
been  found  especially  low  after  death  from  pneumonia,  although 
diminished  amounts  were  also  found  after  measles,  scarlatina,  acute 
febrile  tuberculosis,  malignant  endocarditis.  Since  the  adrenal 
glands  are  not  considered  responsible  for  the  normal  maintenance 
of  blood-pressure,  but  are  regarded  as  emergency  organs,  this 
would  indicate  that  in  order  to  combat  the  hypotension  entailed 
by  these  infectious  processes  the  adrenals  had  been  called  upon  for 
a  reserve  supply,  and  showed  a  corresponding  exhaustion.  The 
decrease  of  residual  epinephrin  encountered  was  never  sufficient 
to  account  for  circulatory  failure. 

During  acute  infections  a  high  diastolic  pressure  has  been  said^ 
to  indicate  splanchnic  stasis  and  in  seriously  ill  patients  to  be  of 
bad  prognostic  significance.  A  low  systolic  and  diastolic  pressure 
does  not  indicate  heart  failure  as  much  as  it  does  diminishing  vis-, 
ceral  tone,  but  a  rising  diastolic  with  a  falling  systolic  pressure  does 
point  toward  cardiac  weakening. 

During  the  height  of  continuous  fevers,  blood  flow  at  the  periphery 
is  somewhat  slower  than  in  health.  The  conditions  are  quite 
different  when  bodily  temperature  is  artificially  raised  by  the 
external  application  of  heat.  In  the  latter  case,  as  was  shown  by 
Hewlett  and  Van  Zwaluwenburg,'  the  peripheral  circulation  is 
enormously  increased,  just  as  it  is  when  a  person  sweats  owing  to 
the  high  temperature  of  a  room.  In  fevers  the  vessels  still  dilate 
under  the  influence  of  external  heat,  but  the  heightened  tempera- 
ture of  the  body  does  not  influence  the  heat-regulatory  mechanism 
in  such  a  way  as  to  cause  their  dilatation.  The  experimental 
researches  of  Newburgh  and  Lawrence''  indicate  that,  in  lower 
animals  degrees  of  hyperthermia  not  greater  than  those  encoun- 
tered in  infections  are  sufficient  to  cause  marked  hypotension.  The 
increased  body  temperature  of  infection  is  a  potent  factor  in  the 
production  of  the  lowered  blood-pressure  which  occurs  in  such  con- 
ditions. The  hyperthermia  may  be  the  entire  cause  of  such  hypo- 
tension. A  temporary  rise  of  pressure  sometimes  accompanies  the 
outbreak   of  the  rash   in  the   exanthemata — scarlatina,   morbili, 


'  Pathological  Changes  in  the  Adrenal  Glands,  Quart.  Jour.  Med.,  1914,  viii.  No.  29. 

*  Schwartzmann :     Zentralbl.  f.  inn.  Med.,  August  1,  1914. 

*  The  Effect  of  Room  Temperature  upon  the  Blood  Flow  in  the  Arm,  etc.,  Heart, 
ii.  230. 

*  The  Effect  of  Heat  on  Blood-pressure,  Arch.  Int.  Med.,  1914,  xiii,  287. 


206     BLOOD-PRESSURE  IN  ACUTE  INFECTIOUS  DISEASE 

variola,  etc.^  The  work  of  the  heart  is  increased  during  fever  if 
the  blood-pressure  remains  constant.^ 

Convalescence  from  prolonged  fevers  is  attended  by  a  loss  of 
splanchnic  tone,  in  part  due  to  depressed  nervous  influence  and  in 
part  to  weakening  of  the  arterial  musculature.  When  the  patient 
assumes  the  erect  posture  there  is  a  marked  falling  of  the  maximal 
pressure,  even  when  the  minimal  pressure  remains  unchanged. 
This  diminishes  the  pulse-pressure,  as  a  result  of  which  the  defi- 
ciency of  cerebral  blood  supply  must  be  compensated  for  by  an 
increased  pulse  rate,  which  throws  an  unnecessary  strain  on  the 
heart.  This  condition  is  often  associated  with  cardiac  murmurs, 
accentuations,  reduplications  or  arrhythmia.  Minor  degrees  of 
physical  exertion  may  cause  a  fall  of  30  to  40  mm.  Hg.  Under  such 
conditions  the  patient  should  not  be  allowed  to  leave  his  bed  so 
long  as  there  is  a  marked  difference  in  pulse  rate  between  the  erect 
and  the  recumbent  postures.  Cardiac  erythism  and  vasomotor 
instability  are  often  encountered. 

As  elsewhere  actual  figures  are  of  little  value.  It  is  the  course  of 
the  pressure,  upward  or  downward,  or  marked  lability,  which  is  of 
importance.  For  this  reason  pressure  readings  should  be  made  and 
charted  simultaneously  with  the  temperature.  Marked  fluctua- 
tions in  the  height  of  the  systolic  pressure  are  of  serious  import. 
Many  of  the  older  reports  on  blood-pressure  in  infectious  disease 
are  practically  useless  because  they  record  only  the  systolic  pressures, 
and  even  these  were  often  made  with  unreliable  instruments. 

The  fact  is  generally  recognized  that  practically  any  infection 
may  produce  cardiovascular  da?nage.  Thayer  found  that  individuals 
who  had  passed  through  attacks  of  typhoid  fever  showed  a  dispro- 
portionately higher  pressure  in  later  life  than  those  who  have  not 
had  this  disease.  The  lesson  is  obvious:  that  convalescents  should 
be  spared  all  unnecessary  activity  for  prolonged  periods  of  time. 
Schwartzmann's^  recent  studies  led  him  to  conclude  that  in  infec- 
tious diseases  a  high  diastolic  pressure  indicates  a  tendency  to 
splanchnic  stasis — a  severe  infection.  A  fall  of  both  systolic  and 
diastolic  pressure  points  to  vasomotor  weakness,  whereas  a  fall  of 
the  systolic,  associated  with  a  rise  of  the  diastolic  pressure  shows 
cardiac  failure.  A  good-sized  and  well-sustained  pulse-pressure  is  a 
favorable  sign. 

'  Weigert,  K. :  Verhalten  d.  art.  Blutdrucks  bei  akuten  Infektionskrankheiten, 
Volkmann's  Samml.  klin.  Vortr.,  1907,  No.  459;  Inn.  Med.,  cxxxviii,  65. 

2  Wolf,  H.  F.:  The  Influence  of  Temperature  on  the  Output  of  the  Heart,  Arch. 
Int.  Med.,  1911,  viii,  463. 

'  Klinische  Bedeutung  der  Feststellung  d.  systolischen  u.  diastolischen  Blutdruck 
bei  Infektionskrankheiten,  Ztschr.  f.  inn.  Med.,  1914,  xxxv,  745. 


DIPHTHERIA  207 

The  venous  pressure  tends  to  fall  with  the  arterial  pressure  in 
infectious  disease,  but  when  cardiac  failure  begins  venous  pressure 
rises. 

ACUTE  INFECTION. 

Cholera. — In  this  disease  the  specific  gravity  of  the  blood  may 
rise  to  1.060  to  1.070,  due  to  loss  of  fluid,  and  systolic  blood-pressures 
as  low  as  70  mm.  Hg.  are  not  rare. 

In  the  algid  stage,  according  to  Lang,^  the  pulse-pressure  decreases 
owing  to  a  fall  of  the  maximum  and  a  rise  of  the  minimum  pressures. 
Diastolic  pressure  diminishes  only  in  severe  cases.  These  changes 
are  due  to  loss  of  the  liquid  constituents  of  the  blood  and  to  conse- 
quent vasoconstriction.  Saline  transfusions  averaging  2  liters  are 
generally  sufficient  to  restore  the  total  volume  of  blood  and  bring 
the  pressure  relations  back  to  the  normal.  Larger  transfusions 
often  lead  to  supernormal  values  as  the  hypertonicity  of  the  vas- 
cular system  tends  to  continue  for  some  time  and  the  pulse  rate  to 
rise.  Following  the  algid  stage  and  during  the  "typhoid"  stage  an 
increased  blood-pressure  is  the  rule. 

The  blood-pressure  is  therefore  a  satisfactory  criterion  of  the 
amount  of  saline  infusion  to  be  administered.  When  given  in  too 
large  quantities  an  unnecessary  amount  of  work  is  thrown  upon 
the  heart.  The  judicious  employment  of  saline  infusion  with  epi- 
nephrin  has  in  one  epidemic  at  least  greatly  lowered  the  mortality 
of  cholera.^  During  the  recent  epidemic  in  Serbia  vaccine  was 
administered  in  large  doses  of  physiological  salt  solution  with  defin- 
itely^ beneficial  results. 

Diphtheria. — Cardiovascular  disturbances  occur  in  about  10 
per  cent,  of  all  diphtheria  cases.  Death  is  due  to  (1)  the  eft'ect  of 
the  toxin  on  the  vasomotor  centre,  heart,  and  adrenals;  (2)  to  myo- 
cardial lesions  (chiefly  parenchymatous) ;  (3)  to  involvement  of  the 
stimulus  conducting  system;  (4)  to  bronchopneumonic  manifes- 
tations.^ 

Experimental  Data. — The  experimental  injection  of  diphtheria 
toxin  does  not  always  cause  an  immediate  fall  of  blood-pressure. 
Such  a  fall  occurs  some  time  after  the  injection  of  cultures  and 

*  Ueber  den  arterielleu  Druck  bei  Cholera  asiatica  u.  s.  Veraeiiderungen  unter  d. 
Einfluss  grosser  Kochsaltzinfusionen,  Deutsch.  Arch.  f.  klin.  Mod.,  1912,  cviii,  236. 

*  Rogers,  L. :  A  Second  Season's  Experience  of  Hypertonic  Transfusions  in  Cholera 
Controlled  by  Observations  on  the  Blood  Changes,  Therap.  Gazette,  November, 
1909,  xxiii,  761. 

^  Leede,  W.  H. :  Beitr.  z.  Diphth.  mit  besonderer  Berucksichtigung  d.  path,  anat.. 
Organ  u.  bacteriologischen  Leiehenblutbefunde  und  ihrem  Verhalten  zuni  klinischen 
Bilde.  (3671  cases).     Ztschr.  f.  khn.  Med.,  1913,  Ixxvii,  297. 


208     BLOOD-PRESSURE  IN  ACUTE  INFECTIOUS  DISEASE 

appears  suddenly.^  Romberg  and  Paessler  showed  that  in  the 
early  stages  at  least  the  hypotension  was  vasomotor  in  origin,  but 
von  Slejskall  was  able  to  show  a  direct  toxic  action  upon  the  heart. 
Lethal  doses  of  diphtheria  toxin  after  a  latent  period  of  twenty-four 
hours  produce  a  marked  fall  of  pressure  up  to  the  point  at  which 
death  occurs.  The  timely  injection  of  antitoxin  delays  this  fall  of 
pressure  and  in  sufficient  dosage  prevents  death,  but  even  in  exces- 
sive dosage  fails  to  restore  a  pressure  which  has  already  fallen 
dangerously  low.^  MacCallum's^  experiments  indicate  that  the 
death  which  occurs  at  the  height  of  an  attack  of  diphtheria  is  not 
exclusively  the  result  of  direct  cardiac  injury,  although  that  may 
have  a  part  in  the  process.  Porter  and  Pratt*  found  that  even  in 
the  late  stages  of  lethal  diphtheria  intoxication  the  vasomotor 
centre  still  responds  to  both  pressor  and  depressor  stimuli,  showing 
that  death  is  not  primarily  due  to  vasomotor  paralysis.  Myers 
and  Wallace^  have  shown  that  although  the  larger  bloodvessels  in 
intoxicated  animals  responded  normally,  the  arterioles  and  capil- 
laries in  the  splanchnic  domain  fail  to  react  normally  to  epinephrin 
and  are  found  in  an  engorged  condition.  It  appears,  therefore, 
that  peripheral  splanchnic  paralysis  accounts  for  the  hypotension 
of  diphtheria. 

Clinical  Data. — Diphtheria  is  accompanied  by  low  arterial  ten- 
sion, the  degree  of  which  often  stands  in  proportion  to  the  severity 
of  the  attack.  The  highest  readings  occur  in  the  first  and  the 
lowest  in  the  second  week  of  the  disease,  normal  tension  being 
reestablished  by  the  seventh  week.  Laryngeal  cases,  especially 
those  requiring  operation,  show  a  higher  pressure  as  a  result  of 
asphyxia.  Tracheotomy  is  often  followed  by  a  sudden  fall  (20  to 
40  mm.).  Pressure  in  the  early  stages  is  ordinarily  not  much 
affected  by  serotherapy;  in  the  latter  stages  it  may  rise  40  per  cent. 
In  cases  manifesting  anaphylactic  phenomena  there  is  a  great  fall 
of  pressure  (see  p.  219). 

Circulatory  weakness  is  a  prominent  feature  of  the  disease,  and 
the  normal  postural  blood-pressure  changes  are  often  absent  or 


•Beck  and  Slapa:     Ueber  d.  Einfluss  d.  Diphtheriegiftes  a.  d.  Kreislauf,  Wien. 
klin.  Wchnschr.,  1895,  vol.  xxui. 

*  Meyer,  Fr.:     Beitr.  z.  Kenntnis  d.  Diphtherievergiftung,  etc.,  Arch.  f.  exp.  Phar., 
1909,  No.  60. 

'  The  Mechanism  of  Circulatory  Failure  in  Diphtheria,  Am.  Jour.   Med.   Sc, 
1914,  cxlvii,  37. 

*  The  State  of   the   Vasomotor   Centre   in   Diphtheria   Intoxication,  Am.  Jour. 
Phj'siol.,   xxxiii,   431. 

5  The  Vascular  Response  in  Poisoning  from  Diphtheria  Toxin,  Proc.  Soc.  Exper. 
Biol,  and  Med.,  1914,  xii,  43. 


MALARIA  209 

reversed  even  during  convalescence.^  The  onset  of  nephritis  is  not 
always  accompanied  by  an  increase  in  blood-pressure. 

There  is  no  fixed  relation  between  fever  and  blood-pressure.  The 
fall  of  the  latter  is  due  to  the  absorption  of  toxins,  as  shown  by 
animal  experiments.  The  most  marked  fall  in  pressure  occurs  in 
those  cases  in  which  antitoxin  treatment  has  been  delayed.  When 
the  fall  of  pressure  is  marked  there  is  usually  more  or  less  cardiac 
involvement.  Intravenous  saline  injection  sometimes  produces 
temporary  improvement,  probably  by  diluting  the  toxins.^  A  fall 
of  pressure  after  an  amelioration  of  acute  symptoms  is  often  the 
first  sign  of  persistent  toxemia.^ 

Fatal  cases  sometimes  show  a  marked  fall  of  pressure  several 
days  before  the  lethal  termination.  A  progressive  fall  of  tension  is 
of  bad  prognostic  import,  as  is  also  a  unilateral  pressure  difference, 
but  high  pressure  does  not  of  necessity  presage  a  recovery. 

As  a  means  of  differential  diagnosis  between  true  diphtheria  and 
simulating  infections,  blood-pressure  readings  are  valueless.  The 
occurrence  of  paralysis  is  sometimes  preceded  by  a  fall  of  pressure 
(Kolossova). 

Malaria. — According  to  Federn,  blood-pressure  rises  during  the 
chill  and  falls  during  the  period  of  sudation.  In  chronic  malarial 
cachexia,  hypotension  is  the  rule.  Lemirne*  has  reported  very  low 
blood-pressure  in  pernicious  malaria  associated  with  cramps,  weak- 
ness, lumbar  pains,  and  white  dermatographism,  the  autopsies 
revealing  hemorrhagic  and  necrotic  suprarenalitis. 

If  some  of  the  recent  hypotheses  regarding  malaria,  which  are 
based  upon  facts  discovered  since  the  artificial  cultivation  of  the 
Plasmodium  has  become  possible,  should  prove  true,  blood-pressure 
may  have  a  more  important  bearing  upon  malaria  than  has  been 
supposed.  It  has  been  suggested  that  after  attaining  a  certain 
size  the  plasmodium  reaches  and  lodges  in  the  capillaries  and  that 
in  this  situation  the  inoculation  of  new  corpuscles  normally  takes 
place.  The  debris  and  pigment  which  result  from  their  destruction 
may,  if  the  infection  be  severe,  "plug"  the  brain  capillaries  and 
produce  "cerebral  malaria."  Further,  the  height  of  the  blood- 
pressure  and  the  state  of  capillary  dilatation  or  constriction  would 
influence  the  stage  at  which  the  organisms  would  recede  from  the 

'  Rolleston,  J.  D. :  Blood-pressure  in  Diphtheria,  British  Jour.  Children's  Dis., 
October,  1911,  v-iii,  28. 

2  CobUner,  W. :  Blutdruckmessungen  bei  erwachsenen  Diphtheriekranken,  Dissert., 
Beriin,  1912,  p.  45. 

'  Schoen,  C:     Deutsch.  med.  Wehnschr.,  March  27,  1913, 

*  Bull,  de  I'Acad.  de  m6d.,  October  17,  1916. 
14 


210     BLOOD-PRESSURE  IN  ACUTE  INFECTIOUS  DISEASE 

peripheral  blood  stream  into  the  capillaries  to  undergo  segmenta- 
tion, or  destruction,  or  to  invade  new  blood  cells.  At  this  point, 
too,  the  organisms  would  be  immune  to  the  effects  of  quinine  which, 
according  to  this  view,  is  not  directly  toxic  but  merely  increases  the 
permeability  of  the  red  cell  to  the  normal  destructive  serum. ^ 

Meningitis. — Epidemic  Cerebrospinal  Meningitis  is  almost  con- 
stantly associated  with  high  intracranial  tension.  Moderately 
increased  blood-pressure  is  not  infrequently  seen  in  the  early  acute 
stage,  during  exacerbations  of  symptoms  late  in  the  disease,  or 
where  the  malady  assumes  a  chronic  aspect.  Often  the  higher  the 
pressure  the  more  severe  the  case.  The  withdrawal  of  cerebro- 
spinal fluid  by  lumbar  puncture,  while  usually  attended  with  a  fall, 
has  no  constant  effect  on  blood-pressure.  It  seems,  therefore,  that 
increased  intracranial  tension  in  meningitis  does  not  necessarily 
cause  a  rise  of  blood-pressure  unless  it  be  late  in  the  disease,  when 
internal  hydrocephalus  may  develop  as  a  result  of  blocking  the 
foramina  of  the  fourth  ventricle.^ 

Tuberculous  Meningitis. — In  tuberculous  meningitis  arterial  press- 
ure is  but  slightly  elevated,  the  readings  obtained  are.  about  nor- 
mal; whereas  in  tuberculous  disease  they  are  generally  subnormal. 
In  other  forms  of  meningitis  very  high  pressures  are  sometimes 
encountered  (230  mm.)  which  sometimes  tend  to  run  a  parallel 
course  with  the  increased  pressure  of  the  cerebrospinal  fluid.^ 

Since  meningitis  is  sometimes  treated  by  intraspinal  injections 
it  is  important  to  know  how  high  the  intraspinal  pressure  may  be 
raised  without  danger.  It  has  been  found  experimentally  that 
although  there  is  a  marked  difference  in  sensitiveness  in  different 
individuals,  a  sudden  increase  of  pressure  is  always  more  dangerous 
than  a  gradual  one.  The  first  mechanical  effect  is  upon  the  respira- 
tory centre,  followed  quickly  by  profound  cardiac  inhibition  which 
causes  a  sudden  and  tremendous  fall  of  blood-pressure.  Inasmuch 
as  this  is  not  a  vasomotor  disturbance,  epinephrin  is  not  indicated. 
In  fact,  it  would  probably  do  harm  on  account  of  its  cardiac  inhibi- 
tive  effect.*  The  best  results  are  obtained  through  the  use  of 
cocain  and  atropin,  the  former  stimulating  the  respiratory  centre 
and  the  latter  lessening  cardiac  inhibition.    (See  Lumbar  Puncture.) 


'  Jour.  Am.  Med.  Assn.,  1914,  Ixii,  1330. 

-  Robinson,  G.  C:  Blood-pressure  in  Cerebrospinal  Meningitis,  Arch.  Int.,  Med. 
May,  1910,  p.  482. 

'  Parisot,  J. :  La  pression  arterielle  dans  les  meningites,  Soc.  Med.  de  Nancy, 
December  8,   1909;  Rev.  Med.  de  I'Est,  1910,  p.  48. 

*  Carter,  W.  S. :  The  Effect  of  Intraspinal  Injections  of  Ringer's  Solution  in 
Different  Amounts  under  Varying  Pressures,  Arch.  Int.  Med.,  1912,  x,  425. 


PNEUMONIA  211 

Pneumonia. — ^The  view  that  death  from  pneumonia  frequently 
results  from  peripheral  vasomotor  paralysis  has  been  quite  generally 
held,  despite  the  fact  that  clinical  observations  are  not  at  all  unani- 
mous in  supporting  this  view.  Among  19  fatal  cases,  and  26  cases 
which  recovered,  Newburgh  and  Minot  found  that  the  systolic 
pressure  in  the  fatal  cases  was  continuously  above  that  in  the  cases 
which  recovered. 

In  1899  Romberg  and  his  associates  endeavored  to  test  the  state 
of  the  vasomotor  mechanism  by  the  use  of  stimuli  to  the  skin  and 
mucous  membranes.  After  producing  a  fatal  pneumococcus  septi- 
cemia in  rabbits,  blood-pressure  was  observed  in  the  animals  after 
electrical  stimulation  applied  to  the  nasal  and  anal  mucous  mem- 
brances.  In  the  early  stages  of  the  disease  sensory  stimuli  always 
caused  a  marked  elevation  of  blood-pressure.  At  a  later  period, 
when  the  appearance  of  the  animals  suggested  the  approach  of 
death  and  the  temperature  was  falling,  the  reflexes  were  still  present 
but  did  not  attain  the  normal  height.  Finally,  when  the  animal 
was  in  a  state  of  collapse  and  death  was  imminent  no  rise  of  blood- 
pressure  followed  peripheral  stimulation.  As  a  result  of  their 
observations,  Romberg  and  his  co-workers  believed  that  they  had 
proved  that  death  in  acute  infectious  diseases  was  the  direct  out- 
come of  paralysis  of  the  vasomotor  centre  in  the  medulla. 

This,  it  is  to  be  observed,  is  an  experiment  of  a  negative  sort, 
since  it  rests  entirely  upon  failure  to  obtain  certain  physiological 
responses. 

Porter  and  Newburgh^  have  recently  completed  experiments 
from  which  they  obtained  positive  information  regarding  this 
problem. 

They  produced  not  only  pneumococcic  septicemia  in  rabbits, 
but  also  acute  fatal  pneumonia  in  rabbits,  cats  and  dogs.  In  order 
to  judge  of  the  condition  of  the  vasomotor  apparatus,  they  measured 
the  vasomotor  reflex.  But  instead  of  using  precarious  reflexes  from 
the  mucous  membranes.  Porter  and  Newburgh  exposed  and  cut 
the  depressor  and  the  sciatic  nerves  and  stimulated  the  central  ends. 

The  data  obtained  are  probably  more  reliable  than  those  first 
mentioned,  since  the  depressor  nerve  is  composed  entirely  of  fibers 
which  affect  the  vasomotor  centres,  whereas  other  nerves  contain 
fibers  of  widely  different  function.  As  a  result  of  these  experiments 
they  found  that  the  vasomotor  centre  was  not  impaired  in  any  of 
the  examples  of  fatal  pneumonia  studied. 

*  The  State  of  the  Vasomotor  Apparatus  in  Pneumonia,  Am.  Jour  Physiol.,  1914, 

XXXV,   1. 


212    BLOOD-PRESSURE  IN  ACUTE  INFECTIOUS  DISEASE 

It  is  not  surprising,  therefore,  that  low  blood-pressure  in  pneu- 
monia is  not  invariably  of  evil  omen,  indeed  the  systolic  pressure 
is  often  higher  in  fatal  than  in  non-fatal  cases,  and  hence  Gibson's 
rule  is  far  from  infallible.  The  rate  of  the  pulse  and  not  the  blood- 
pressure  level,  is  the  chief  factor  in  deciding  whether  the  pressure 
will  or  will  not  fall  below  the  pulse.^ 

On  the  other  hand,  as  opposing  the  view  that  pneumonic  death 
is  primarily  a  cardiac  failure,  it  has  been  shown  that:  (1)  The  heart 
muscle  is  not  functionally  impaired  in  pneumonia  since  the  pneu- 
monic ventricle  beats  normally  as  soon  as  its  food  is  normal;  (2) 
pneumonic  blood,  suddenly  fed  to  a  normal  heart  muscle,  lowers  its 
efficiency,  lessening  the  duration  and  the  area  of  contraction;  (3) 
the  heart  muscle  in  pneumonia  gradually  exposed  to  the  action  of 
the  poison,  largely  adjusts  itself  to  its  poisoned  food.^  Insofar  as 
experimental  data  go,  therefore,  we  are  left  in  a  quandary.  The 
vasomotor  centre  is  not  impaired  and  the  heart  muscle  is  still  effi- 
cient, yet  the  patient  dies  a  circulatory  death.  In  answer  to  this 
Porter  has  suggested  that  the  brain  centre  which  controls  arterial 
tonus,  and  that  which  regulates  vasomotor  reflexes,  are  not  identical. 
Another  explanation  offered  by  Boothby^  is  that  there  exists  a 
subordinate  circulatory  centre  which  acts  in  combination  with  the 
respiratory  centre. 

Death  in  pneumonia  is  often  attended  with  the  same  symptoms 
as  those  produced  by  surgical  "shock."  There  is  often  no  dilata- 
tion or  engorgement  of  the  right  heart.  In  lobar  pneumonia  there 
is,  in  addition  to  hypotension,  the  added  mechanical  obstruction 
in  the  lungs  with  which  the  right  heart  has  to  cope.  Pulmonary 
involvement  is  often  extensive,  but  experiments  have  demonstrated 
that  one-sixth  of  the  total  lung  capacity  is  sufficient  to  maintain 
life,*  and  in  the  advanced  stages  of  tuberculosis  an  individual  often 
lives  for  weeks  or  months  with  very  little  lung  tissue  intact.  It  is 
not,  therefore,  the  extent  of  the  pulmonary  lesion  which  is  of  pri- 
mary importance  in  pneumonia  but  the  degree  of  toxemia,  and  this 
is  often  reflected  in  blood-pressure  estimations. 

The  Pulse  Rate — Blood -pressure  Ratio. — Gibson  suggested  that  the 
ratio  of  pulse  rate  and  blood-pressure  may  be  of  some  prognostic 


'  Newburgh  and  Minot:     Arch.  Int.  Med.,  1914,  xiv,  48.     Newburgh:     Am.  Jour. 
Med.  Sc,  February,  1915,  p.  204. 

2  Newburgh,  L.  H.,  and  Porter,  M.  T.:     The  Heart  Muscle  in  Pneumonia,  Jour. 
Exper.  Med.,  1915,  xxii,  123. 

3  Jour.  Am.  Med.  Assn.,  1915,  Ixv,  959. 

^Bernard,  L.,  Le  Play,  Mantoux,  C:     Capacite  pulmonaire  minima  compatible 
avec  la  vie.  Jour,  de  physiol.  Exp6r.,  1913,  xv,  16. 


PNEUMONIA  213 

value.  "A  pressure  appreciably  below  the  normal  in  pneumonia 
is  invariably  of  evil  omen,  and  any  considerable  fall  bodes  disaster. 
When  the  arterial  pressure,  expressed  in  millimeters  of  mercury, 
does  not  fall  below  the  pulse  rate  expressed  in  beats  per  minute, 
the  fact  may  be  taken  as  of  excellent  augury,  while  the  converse  is 
equally  true."  This  statement  has  found  corroboration  from  some 
sources  but  is  certainly  far  from  infallible.^ 

The  pulse-pressure  ratio  must  not  be  accepted  too  literally;  for 
individuals  who  have  habitually  a  high  pressure  may,  when  criti- 
cally ill,  show  a  more  favorable  ratio  than  their  condition  justifies. 
On  the  other  hand,  patients  with  essential  hypotension  may  show 
a  lower  pressure  while  their  actual  condition  may  be  quite  satis- 
factory. HowelP  has  found  that  in  doubtful  cases  observation  of 
the  relative  intensity  and  duration  of  the  first  four  auscultatory 
phases  may  be  distinctly  helpful.  Strong,  clear-cut  sounds  over  an 
d.rtery  are  indications  of  circulatory  strength.  This  applies  especially 
to  the  third  phase  in  pneumonia. 

"More  is  to  be  gained  from  watching  the  changes  in  a  succes- 
sion of  sequences  than  from  isolated  observations,  for,  indeed,  one 
patient  may  be  quite  comfortable  with  a  sequence  which  in  another 
promises  the  worst."  In  pneumonia  the  persistence  of  the  second 
phase,  which  is  most  readily  lost,  is  of  favorable  import.  All  clear 
tapping  sounds  are  of  good  augury,  whether  heard  in  that  part  of 
the  sequence  usually  assigned  to  the  third  phase  or  not,  whereas 
feeble,  muffled  sounds  must  be  considered  as  unfavorable.  "When 
the  clear  tap  is  lost  and  the  sequence  appears  as  a  succession  of 
dull,  muffled  sounds  from  systole  downward,  a  high  grade  of  per- 
ipheral relaxation  and  secondary  cardiac  exhaustion  can  be  inferred. 
When  to  this  arrhythmia  is  added,  the  worst  picture  is  drawn." 

There  is  no  constant  relation  between  blood-pressure  and  the 
occurrence  of  crisis.  As  a  rule  pressure  is  lower  after  the  crisis 
than  before,  and  a  gradual  return  to  the  normal  occurs  yari  passu 
with  convalescence.  Hypertensive  cases  often  have  a  lowered 
pressure  during  the  course  of  the  disease. 

Venous  pressure  is  low,  but  rises  as  cardiac  weakness  increases. 

The  benefcial  effects  of  cold  fresh  air  are  unquestionable,  but 
they  cannot  be  explained  as  the  result  of  any  direct  effect  upon 
blood-pressure.    A  slight  rise  of  systolic  pressure  of  variable  dura- 


1  Goodman  and  Pitman:  Therap.  Gazette,  July  15, 1911.  Tice:  Am.  Jour.  Med.  Sc;., 
1916,  clii.  No.  1. 

2  Possibilities  in   the   Use  of  the   Auscultatory   Method   of   Determining   Blood- 
pressure  in  Pneumonia,  Jour.  Am.  Med.  Assn.,  1914,  Ixii,  1230. 


214.    BLOOD-PRESSURE  IN  ACUTE  INFECTIOUS  DISEASE 

tion  is  produced  in  normal  adults  by  exposure  of  the  face  to  cold 
air,  but  is  often  followed  by  a  fall  to  the  original  level  even  while 
the  exposure  is  continued.^  Van  Ordt,^  it  is  true,  found  a  slight 
rise  of  blood-pressure  following  exposure  to  cold,  but  not  greater  in 
amount  than  the  normal  physiological  range.  Barringer  obtained 
practically  negative  results,  regardless  of  whether  the  entire  body 
or  only  the  face  was  exposed. 

In  children,  however,  Rowland  and  Hoobler*  always  found  a  rise 
of  pressure  beginning  one  hour  after  exposure  to  cold  air,  reaching 
its  maximum  in  two  hours,  and  persisting  as  long  as  the  child  was 
kept  out.  Keturn  to  the  ward  was  followed  in  twenty  minutes 
by  a  fall  which  reached  its  maximum  in  one  hour.  Reexposure 
induced  a  second  rise.  Convalescents  showed  less  striking  results 
than  the  febrile  cases.  In  warm  weather  the  pressor  effect  of  out- 
door air  was  lacking,  showing  that  the  vascular  reflex  was  due  to 
the  lowered  temperature.  Only  the  face  being  exposed,  the  increased 
blood-pressure  probably  resulted  from  central  vasomotor  constric- 
tion, resulting  from  stimulation  of  the  nasal  mucosa.  These  find- 
ings are  directly  at  variance  with  those  of  Morse  and  Hassman.'' 

Some  cases  of  type  I  pneumonia  show  an  increased  pressure 
(10  to  15  mm.)  both  systolic  and  diastolic  after  the  administration 
of  serum. 

Scarlet  Fever. — ^The  fall  of  pressure,  which  occurs  in  about  25 
per  cent,  of  the  cases,^  is  less  than  in  typhoid  fever,  and  stands  in 
direct  relation  to  the  severity  of  the  attack.  It  appears  during  the 
period  of  eruption  and  is  pronounced  during  febrile  defervescence. 
In  mild  cases  pressure  is  but  slightly  affected.  In  grave  cases  a 
marked  fall  is  associated  with  a  high  temperature  and  a  rapid  pulse. 
The  normal  is  gradually  reestablished  during  convalescence,  more 
slowly  after  severe  cases.  Slight  albuminuria  may  not  be  accom- 
panied by  a  rise  of  pressure.*  In  scarlatinal  nephritis,  blood-pressure 
sometimes  rises  before  albumin  has  appeared  in  the  urine.  Cardiac 
involvement  is  sometimes  associated  with  a  slight  rise  and  marked 
lability  of  arterial  pressure  (Weigert).     Dietary  modifications — 


'  Barringer,  T.  B. :  The  Effect  of  Cold  Air  upon  the  Circulation  in  Healthy  and 
Sick  Individuals,  Am.  Jour.  Med.  Sc,  1912,  cxliv,  233. 

« Ztschr.  f.  Diat.  u.  physik.  Therap.,  1905,  ix,  338. 

'  Effect  of  Cold,  Fresh  Air  on  the  Blood-pressure  in  Pneumonia  in  Children,  Am. 
Jour.  Dis.  Child.,  1912,  iii,  294. 

*  Am.  Jour.  Dis.  Child.,  November,  1916. 

'  Rolleston,  J.  D. :  The  Blood-pressure  in  Scarlet  Fever,  British  Jour.  Child.  Dis., 
1912,  ix,  444. 

'  Teissier  and  Tanon:  Le  Pression  art^rielle  dans  la  Scarlatine  de  I'Adulte,  Jour. 
Physiol,  et  Path.  G6nerale,  1908,  x,  481. 


TYPHOID  AND  PARATYPHOID  FEVER  215 

milk,  salt,  salt-free  food — and  minor  complications  have  but  little 
effect  on  blood-pressure.^ 

Smallpox. — ^The  pustulation  stage  is  associated  with  a  fall  of 
arterial  pressure  which  compares  in  degree  to  the  toxemia.  A 
return  to  the  normal  during  convalescence  occurs  very  slowly.^ 

Typhoid  and  Paratyphoid  Fever. — ^The  blood-pressure  in  typhoid 
fever  falls  below  the  normal  after  the  patient  takes  to  his  bed  and 
remains  low  until  convalescence  is  established.  This  is  the  result  of 
toxic  vasomotor  depression.  The  fall  of  pressure  bears  no  constant 
relation  to  the  pulse  or  temperature  curve  or  the  severity  of  the 
attack,  but  a  rapid  or  progressive  fall  of  pressure  is  often  of  serious 
augury.  The  value  of  blood-pressure  readings  as  a.  means  of  differ- 
ential diagnosis  or  prognosis  is  not  of  much  value.' 

Both  systolic  and  diastolic  pressure  fall  during  the  later  febrile 
period,  and  rise  coincidently  at  the  beginning  of  the  afebrile  period. 
Later  on  in  convalescence  the  systolic  and  diastolic  levels  move 
farther  and  farther  apart,  owing  either  to  a  systolic  rise  and  a 
diastolic  fall  or  because  the  one  pressure  remains  stationary  while 
the  other  recedes  from  it.  Finally,  sometimes  suddenly  and  at 
times  coincidently  with  leaving  bed,  both  pressures  attain  a  higher 
level.  Studies  of  the  "pulse-pressure  quotient"  and  the  "amplitude 
frequency  product"  indicate  that  during  the  febrile  period  the 
heart  performs  increased  work  despite  the  lowered  pressure,  and 
that  circulatory  weakness  is  in  part  cardiac  and  in  part  vasomotor 
in  origin.  Further,  that  in  one  case  which  came  to  autopsy,  toxemia 
was  accountable  for  the  condition,  since  no  microscopic  myocardial 
lesions  were  encountered  (Fig.  87).'* 

In  115  cases  the  average  pressure  was  found  to  be:  First  week, 
115  mm.;  second,  106  mm.;  third,  102  mm.;  fourth,  96  mm.;  fifth, 
98  mm.  The  occurrence  of  perforation  is  often  followed  within  two 
to  four  hours  by  a  rise  of  from  20  to  70  mm.  It  is  caused  by  (a) 
pain,  and  (b)  beginning  peritonitis,  in  the  early  stages  of  which 
condition  a  marked  pressure  increase  is  often  seen.^  In  the  later 
stages  a  toxic  paralysis  of  the  vasomotor  and  respiratory  centres 
in  the  medulla  occurs  (Romberg  and  Heineke). 

1  Nobecourt  and  Teissier:  La  Pression  art6rielle  dans  la  Scarlatine  de  I'Adulte, 
Jour.  Physiol,  et  Path.  Gen6rale,  1908,  x,  481. 

^  Davidson:   Blood-pressure  in  Fevers,  Lancet,  October  19,  1907. 

'  Weigert,  K. :  Ueber  d.  Verhalten  d.  arteriellen  Blutdrucks  bei  d.  akuten  Infek- 
tionskrankheiten,  Samml.  klin.  Vortrage,  1907,  xvi,  No.  9. 

*  Dietschy,  R.,  and  Hossli,  H.:  Beitrage  z.  Beurteilung  d.  Kreislaufsverhaeltnisse 
bei  Infektionskrankheiten,  etc.,  Deutsch.  med.  Wchnschr.,  April  24,  1908,  vol.  xciii. 

*  Crile,  G.  W.:  The  Diagnostic  Value  of  Blood-pressure  Observations  in  the  Diag- 
nosis of  Typhoid  Perforation,  Jour.  Am.  Med.  Assn.,  1903,  xl,  1292. 


216    BLOOD-PRESSURE  IN  ACUTE  INFECTIOUS  DISEASE- 

The  occurrence  of  a  relapse  bears  no  constant  relation  to  blood- 
pressure.  In  some  cases  this  phenomenon  is  preceded  by  a  rise,  in 
others  by  a  fall  of  pressure. 


AMPLITUDE- 

FREcuENCY       5r280     7176    5772     4200      3552 

PRODUCT 


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140  0.2 
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130  .150 
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110  130 


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90   10 

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40°  0 

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FlG.  87. — Record  of  a  rapidly  fatal  case  of  typhoid 
fever  in  which  death  apparently  resulted  from  cardiac 
weakness.  The  systolic  pressure  falls,  the  diastolic 
pressure  rises,  the  quotient  and  the  amplitude  fre- 
quency product  steadily  decline,  while  the  venous 
pressiu-e  and  the  pulse  rate  rise.  Microscopic  exam- 
ination of  the  heart  being  negative,  death  was 
ascribed  to  toxic  factors.     (Dietschy  and  Hossli.) 


Fig.  88.— Key  to  Fig. 
87:  a,  maximum  pressure; 
6,  minimum  pressure;  c, 
temperature;  d,  pulse  rate; 
e,  blood-pressure  quoti- 
ent; /,  pressure  of  the 
jugular  vein. 


During  cmnalescence  there  is  a  slow,  gradual  rise  of  pressure 
(sometimes  interrupted  by  temporary  drops),  which  increases  more 


TYPHOID  AND  PARATYPHOID  FEVER  217 

rapidly  when  the  patient  is  again  up  and  about.  RoUeston^  found 
that  93  per  cent,  of  his  cases  showed  a  fall  of  pressure  on  assuming 
the  erect  posture.  This  observation,  represents  the  usual  occur- 
rence of  cardiac  and  vasomotor  weakness  which  an  attack  of  typhoid 
fever  entails.  I  have  found  the  emplojTnent  of  Crampton's  test  a 
useful  guide  regarding  the  length  of  time  which  convalescents  may 
be  permitted  to  sit  up  or  the  amount  of  exercise  in  which  they  may 
be  allowed  to  indulge.  Not  infrequently  blood-pressure  remains 
subnormal  for  weeks  and  even  months  after  the  actual  fever  has 
subsided. 

Thayer^  pointed  out  the  fact  that  patients  who  had  had  typhoid 
fever  not  infrequently  showed  evidences  of  arteriosclerosis  and 
arterial  hypertension  out  of  proportion  to  their  age.  Hemorrhage 
is  usually  followed  by  a  fall,  sometimes  a  marked  fall,  of  pressure 
(20  to  40  mm.).  In  cardiac  weakness  marked  diurnal  variations 
may  occur. 

Cold  sponging  raises  the  pressure  10  to  15  mm.  in  cases  which 
respond  favorably  to  the  treatment;  in  the  cases  which  become 
cyanotic,  this  rise  does  not  occur.  A  complicating  pneumonia 
may  temporarily  raise  the  pressure,  as  may  also  the  psychic  effect 
of  too  many  visitors.^  To  be  of  any  value  in  typhoid  fever  blood- 
pressure  observations  should  be  made  twice  daily.  The  normal 
individual  range  will  then  be  established  and  changes  definitely 
demonstrated.  If  perforation  is  anticipated  readings  should  be 
made  at  half-hourly  intervals. 

Loeper^  has  reported  low  blood-pressure  associated  with  cj^anosis, 
myalgia  and  diarrhea  occurring  on  the  evening  or  the  day  following 
the  first  dose  of  antityphoid  inoculation.  These  symptoms  were 
relieved  by  epinephrin,  which  he  believes  should  be  used  as  a  pro- 
phylactic. 

The  Treatment  of  Febrile  Hypotension. — Hypotension  per  se  is  not 
a  symptom  calling  for  treatment  any  more  than  is  hypertension. 
The  resting  body  can  do  with  a  pressure  well  below  the  normal 
without  deleterious  effects;  indeed,  this  may  be  a  method  of  con- 
serving energy.  Only  when  pressure  falls  progressively  or  is  accom- 
panied by  other  signs  of  cardiac  or  vasomotor  failure  is  interference 
warranted.  Many  a  case  of  typhoid  fever  or  pneumonia  weathers 
the  attack  satisfactorily,  having  a  systolic  pressure  of  about  100 
mm.  Hg.,  without  stimulation. 

'  Blood-pressure  in  Typhoid  Fever,  Med.  Press  and  Circular,  March  15,  1916. 
2  Bull.  Johns  Hopkins  Hosp.,  1904,  xv,  313;  Am.  Jour.  Med.  Sc,  1904,  cxxvii,  391. 
'  Barach:   Blood-pressure  in  Typhoid  Fever,  N.  Y.  Med.  Jour.,  August  24,  1907. 
*  Presse  M6dicale,  October  19,  1916. 


218    BLOOD-PRESSURE  IN  ACUTE  INFECTIOUS  DISEASE 

When,  however,  a  falling  pressure  is  associated  with  an  increased 
pulse  rate,  pallor,  sweating,  cold  extremities,  and  other  signs  of 
collapse,  direct  treatment,  calculated  to  restore  vasomotor  tone,  is 
indicated.  It  is  generally  easier  to  keep  up  pressure  by  early  treat- 
ment— sponging,  etc. — than  to  restore  it  once  it  has  fallen  to  the 
danger  limit.  The  best  results  will  usually  be  obtained  by  fresh 
air,  cold  sponging,  saline  enteroclysis,  or  intravenous  infusion.  The 
addition  of  from  0.5  to  1  per  cent,  of  sodium  bicarbonate  to  the 
0.8  per  cent,  sodium  chloride  solution  is  advisable.  The  addition 
of  the  former  salt  produces  a  greater  rise  of  the  diastolic  pressure 
and  seems  to  exert  a  definitely  stimulating  effect  upon  the  heart^ 
(see  p.  401).  In  the  course  of  fever  the  peripheral  circulation,  as 
indicated  by  the  flow  of  blood  in  the  foot,  is  distinctly  subnormal. 
This  apparently  results  from  vasoconstriction,  an  effort  on  the 
part  of  Nature  to  secure  an  increased  blood  flow  for  the  organs 
chiefly  involved.  According  to  this  hypothesis,  fever  is  due  to 
more  rapid  flow,  and  therefore  increased  metabolism  of  the  internal 
organs.  Hence,  cold  sponging  would  seem  to  be  the  most  valuable 
form  of  treatment,  since  it  tends  to  abet  the  natural  process;  whereas 
antipyretic  and  other  vasodilator  drugs  are  directly  contra-indicated, 
since  they  tend  to  interfere  with  the  natural  mechanism  of  healing.  ^ 
The  application  of  an  ice-hag  to  the  precordium  is  often  useful  since 
it  not  only  slows  the  heart  but  increases  blood-pressure.  Since 
febrile  hypotension  is  essentially  toxic  in  nature,  all  available  means 
must  be  employed  to  counteract  or  minimize  toxemia.  Febrile 
hypotension  is  often  associated  with  tympanites,  which  symptom 
should  be  zealously  guarded  against,  since  it  indicates  indigestion 
and  malnutrition,  and  because  it  seriously  embarrasses  both 
respiration  and  heart  action. 

Treatment  therefore  should  consist  of:  1.  Combating  Toxemia. 
This  is  to  be  accomplished  by  increasing  elimination  by  attention 
to  the  emunctories.  Proper  evacuation  of  the  bowels  and  increas- 
ing the  urinary  output  are  useful  measures.  The  latter  is  often 
best  accomplished  by  increasing  the  fluid  intake;  by  mouth,  by 
means  of  continuous  enteroclysis  (drip  method),  by  intravenous 
saline  infusion  or  hypodermoclysis.  Fresh  air  plays  an  important 
role. 

2.  Vasomotor  stimulation,  by  cold  sponging  or  tubbing,  or  by  the 

'  Dawson:  The  Changes  in  the  Heart-rate  and  Blood-pressure  Resulting  from 
Severe  Hemorrhages  and  Subsequent  Infusion  of  Sodium  Bicarbonate,  Jour.  Exp. 
Med.,  1905,  \'ii.  1. 

*  Stewart.  G.  N.:  Blood  Flow  in  the  Feet,  with  Special  Reference  to  Fever,  Jour. 
Exp.  Med.,   1913,  xviii,  354. 


MEDICAL  OR  TOXIC  SHOCK  219 

use  of  drugs  which  act  upon  the  central  or  peripheral  vasomotor 
system. 

The  drugs  most  commonly  employed  are  strychnin,  atropin, 
cafFein,  camphor,  digitalis,  strophanthus,  pituitrin,  epinephrin. 
Although  they  may  do  good,  improvement  cannot,  except  in  case 
of  the  last  two,  be  attributed  to  direct  blood-pressure  raising 
qualities  (see  under  Therapeutics). 

Medical  or  Toxic  Shock. — A  condition  of  shock  clinically  identical 
with  that  seen  after  surgical  trauma  may  occur  as  the  result  of 
anaphylaocis.  The  injection  of  foreign  proteins,  horse  serum  for 
instance,  is  sometimes  followed  by  sudden  collapse  or  even  death 
from  this  cause.  A  distinction  is  often  made  between  shock  and 
collapse.  In  the  former  we  are  dealing  with  a  lowering  of  vaso- 
motor tone  due  to  insufficient  reflex  splanchnic  stimulation;  in  the 
latter  the  vasomotor  paresis  is  due  to  depression  resulting  from 
toxemia.  Pearce  has  shown  experimentally  that  in  both  anaphy- 
lactic shock  and  in  peptone  intoxication  in  dogs  there  is  a  great 
fall  of  blood-pressure  (20  to  30  mm.  Hg.)  due  to  splanchnic  dilata- 
tion and  resulting  in  medullary  anemia.  Cardiac  and  respiratory 
abnormalities  are  entirely  secondary  manifestations. 

That  there  is,  however,  a  difference  between  toxic  shock  and  that 
due  to  hemorrhage,  is  shown  by  the  different  response  to  nicotin 
and  epinephrin.  In  anaphylactic  and  peptone  shock  during  the 
hypotensive  period  the  pressor  effect  of  nicotin  may  be  increased 
at  a  time  when  epinephrin  is  ineffective,  whereas  in  the  hypoten- 
sion of  hemorrhage  although  the  nicotin  reaction  may  be  abnormally 
intense,  epinephrin  still  produces  vasoconstriction  and  increase  of 
blood-pressure.^  Simonds  believes  that  this  indicates  a  state  of 
reduced  irritability  in  the  vasomotor  centre,  and  attributes  the 
increased  nicotin  reaction  to  its  mechanical  effect  upon  respiration. 
The  dyspnea  so  produced  causes  suction  on  the  overfilled  non- 
collapsible  veins  of  the  liver  and  brings  sufficient  blood  to  the 
unfilled  right  side  of  the  heart  and  ultimately  to  the  systemic  ves- 
sels, in  which  pressure  is  raised. 

Physiological  studies  having  for  their  object  the  determination  of 
the  mechanism  by  which  the  low  pressure  is  caused,  demonstrate 
that  the  condition  is  essentially  a  peripheral  vasomotor  paralysis. 
Pharmacological  studies  indicate  that  the  effect  is  on  the  nerve 
endings  rather  than  on  the  muscle. 

With  independent  cerebral  transfusion  the  recovery  from  low 

'  Simonds,  J.  P. :  Low  Blood-pressure  not  Associated  with  Trauma  or  Hemorrhage, 
Arch.  Int.  Med.,  1916,  xviii,  848. 


220    BLOOD-PRESSURE  IN  ACUTE  INFECTIOUS  DISEASE 

pressure  is  more  rapid  than  in  the  intact  animal.  This  is  true  also 
when  an  animal  is  transfused  by  carotid  anastomosis,  and  recovery 
is  especially  satisfactory  when  the  transfusion  is  accompanied  by 
simultaneous  bleeding  from  the  femoral  vein. 

The  researches  of  Auer  and  Robinson^  indicate  that  in  animals 
at  least,  the  fall  of  pressure  seen  in  anaphylactic  shock  may  be 
partially  cardiac  in  origin.  The  electrocardiogram  shows  variable 
abnormalities,  ranging  from  an  increased  depression  of  the  S-wave 
to  complete  dissociation  of  stimulus  conduction. 

Henderson  and  Barringer  state  that  "in  both  hemorrhage  and 
circulatory  shock  the  decrease  in  the  venous  supply  to  the  right 
heart  is  the  critical  factor.  In  this  they  differ  from  vasomotor 
failure,  in  which  the  peripheral  resistance  of  the  arterial  system  is 
decreased." 

"The  indications  for  treatment  therefore  appear  to  be  (1)  relief 
of  splanchnic  congestion,  and  (2)  increase  of  volume  of  blood  to 
the  heart  and  medulla.  Cardiac  stimulants  alone,  or  salt  solution 
and  adrenalin  alone,  cannot  bring  about  a  permanent  improvement. 
A  combination,  however,  of  the  slow  injection  of.  adrenalin  in  salt 
solution  (1  to  40,000)  intravenously  with  the  addition  of  a  pure 
cardiac  stimulant,  as  digitoxin,  leads  to  relatively  rapid  and  per- 
manent improvement,  by  promoting  a  determination  of  the  blood 
to  the  right  heart  and  increasing  the  circulation  in  the  brain" 
(Pearce).^ 

As  a  prophylactic  measure  in  anaphylactic  shock,  the  utility  of 
atropin  has  been  demonstrated  by  Auer.^  In  guinea-pigs  without 
atropin,  75  per  cent,  died;  with  this  drug  only  28  per  cent,  (see 
Surgical  Shock,  p.  396). 

THE  EFFECT   OF  DRUGS   ON   THE  VASOMOTOR  SYSTEM. 

Strychnin,  while  it  may  be  useful  in  other  ways,  does  not  stimulate 
the  vasomotor  centre  except  in  toxic  doses. 

Epinephrin  has  no  direct  effect  on  the  centre,  but  may  be  useful 
iri  emergency  for  its  sympathetic  stimulation. 

Camphor  is  probably  without  effect  on  the  centre,  as  is  also 
spartein.  Ergot  increases  pressure  by  its  stimulation  of  the  sympa- 
thetic nerve. 

1  An  Electrocardiographic  Study  of  the  Anaphylactic  Rabbit,  Jour.  Exp.  Med., 
1913,  xviii,  450. 

'  A  Study  of  Experimental  Conditions  of  Low  Blood-pressure  of  Non-traumatic 
Origin,  Archiv.  Int.  Med.,  August,  1910,  vi,  218;  also,  A  Study  of  the  Action  of 
the  Heart  in  Anaphylactic  Shock  in  a  Dog,  Jour.  Phar.  and  Exp.  Therap.,  1912,  iv, 
No.  1.  '  Am.  Jour.  Physiol.,  September,  1910. 


THE  EFFECT  OF  DRUGS  ON  THE   VASOMOTOR  SYSTEM    221 

The  vasomotor  centre  is  depressed  by  chloroform;  ether  stimu- 
lates moderately,  if  it  has  any  effect.  Pituitrin  has  but  a  slight 
action  on  the  centre.  It  is  a  useful  emergency  measure  which  raises 
pressure  by  its  action  on  the  peripheral  arterial  muscle.^  Alcohol 
is  deleterious  if  increase  of  pressure  is  the  desideratum. 

If  the  hypotension  results  from  cardiac  weakness,  digitalis  or 
strophanthin  may  be  tried,  although  their  effects  are  often  disap- 
pointing in  febrile  toxemia.  An  ice-bag  applied  to  the  precordium 
is  often  the  most  satisfactory  method  of  steadying  the  heart. 

1  Pilcher  and  SoUmann:  Studies  on  the  Vasomotor  Centre,  Jour.  Phar.  and  Exp. 
Therap.,  1915,  vi,  323. 


CHAPTER  VIII. 
BLOOD-PRESSURE  IN  CHRONIC  INFECTIOUS  DISEASE. 

Syphilis  .^ — Owing  to  the  great  frequency  of  aortitis  as  a  lesion 
of  secondary  syphilis,  and  since  it  so  often  involves  the  mouths  of 
the  coronary  arteries,  it  is  not  surprising  that  blood-pressure  varia- 
tions and  other  cardiac  symptoms  should  frequently  be  encoun- 
tered. Two-thirds  of  the  228  cases  studied  by  Grassmann*  showed 
cardiac  disturbances — arrhythmia,  bradycardia,  tachycardia,  mur- 
murs, dilatation,  etc.  He  found  that  the  blood-pressure,  which  is 
normal  at  first,  soon  gives  place  to  hypotension  and  instability. 
As  soon  as  aortic  valvular  leakage  is  established,  the  pressure 
changes  take  on  the  characteristic  manifestations  of  this  lesion 
(see  p.  242).  In  80  per  cent,  of  Grassmann's  cases  the  pressure 
(von  Basch  sphygmomanometer)  was  below  80  mm.  in  the  tem- 
poral artery.  Some  of  these  cases  showed  a  further  reduction  of 
both  pressure  and  hemoglobin  on  the  institution  of  the  mercurial 
treatment. 

Based  upon  a  study  of  50  hypertensive  cases,  90  per  cent,  of  which 
yielded  either  a  positive  Wassermann  or  luetin  test,  Stoll-  has 
advanced  the  hypothesis  that  hereditary  syphilis  is  one  of  the  most 
common  causes  of  hypertensive  disease.  He  lays  stress  on  the 
importance  of  performing  a  luetin  test,  especially  if  activated 
by  a  week's  mixed  treatment  in  hypertensive  cases  which  have 
yielded  a  negative  Wassermann  test.  He  reports  favorable  results 
from  specific  treatment  especially  in  patients  with  pressures  below 
200  mm.  Hg.  without  any  apparent  deleterious  effects  upon  the  kid- 
ney, even  in  cases  in  which  the  phthalein  excretion  was  consider- 
ably reduced.  The  best  results  were  obtained  by  administering  mer- 
cUry  by  inunction,  and  potassium  iodide  by  mouth  (see  Salvarsan, 
p.  354),  Although  the  actual  degree  of  hypertension  is  as  a  rule 
unaffected  by  antiluetic  treatment,  occasionally  marked  reductions 
in  blood-pressure  are  produced.^ 

'  Klin.  UntersiK'h.  a.  d.  Kreislauforganen  in  Frlihstadium  d.  Syphilis,  Deutsch 
Arch.  f.  klin.  Med.,  1901,  Ixix,  281. 

2  The  Role  of  Syphilis  in  Hypertensive  Cardiovascular  Disease,  Am.  Jour.  Med. 
Sc,  1915,  cl,  178. 

'  Levinson,  L.  A.:  Results  of  Treatment  in  Arterial  Hypertension  Due  to  or 
Associated  with  Syphilis,  Jour.  Am.  Med.  Assn.,  1916,  Ixvii,  730. 


TUBERCULOSIS 


223 


Tuberculosis. — Tuberculous  disease  is  usually  mentioned  as  one 
of  the  conditions  in  which  arterial  tension  is  subnormal.  This 
statement  appears  to  be  correct  insofar  as  the  late  stages  of  the 
disease  are  concerned,  when  toxemia  and  emaciation  are  pronounced. 
In  the  early  stage,  especially  at  the  time  when  the  diagnosis  is  still 
in  doubt,  normal  pressure  is  found.  Janeway's^  recently  published 
charts  which  are  here  reproduced,  show  a  close  similarity  between 
tuberculous  office  patients  and  normal  individuals.  These  state- 
ments are  also  corroborated  by  Shalet,^  who  studied  1000  cases  at 
the  Otisville  Sanatorium. 


SYS. 
PRESS. 

140 
135 
130 
125 
120 

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Fig.  89. — Median  systolic  blood-pressures,  arranged  by  age  periods.  Personal 
observations.  (Figures  in  brackets  at  right  of  curves  indicate  total  number  of 
individuals  observed  in  each  group.) 


DIAST. 
PRESS. 

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-TUBERCULOSIS                                                      1 

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Fig.  90. — Median  diastolic  blood-pressures,  arranged  by  age  periods.  Personal 
observations.  (Figures  in  brackets  at  right  of  curves  indicate  total  number  of 
individuals  observed  in  each  group.) 

As  in  health,  the  pressures  are  lower  in  tuberculous  women  than 
in  men.  Blood-pressure  bears  no  definite  relation  to  the  stage  of 
the  disease,  although  it  generally  does  to  the  degree  of  toxemia. 


^  Important  Contributions  to  Clinical  Medicine  during  the  Past  Thirty  Years 
from  the  Study  of  Human  Blood-pressure,  Tr.  Assn.  Am.  Phys.,  1915,  xxx,  27. 

2  Blood-pressure  in  Pulmonary  Tuberculosis,  New  York  State  Jour.  Med.,  1914, 
xiv,  189. 


224     BLOOD-PRESS URE  IN  CHRONIC  INFECT  10 US  DISEASE 

Thus  the  pulse  rate  and  the  degree  of  temperature  sometimes, 
although  by  no  means  always,  bear  &n  inverse  relation  to  blood- 
pressure.  A  complicating  nephritis  may  cause  a  rise  of  pressure, 
but  rarely,  if  ever,  to  the  degree  attained  in  non-tuberculous  cases. 
In  the  literature  on  the  subject  there  is,  however,  much  room  for 
uncertainty,  since  the  term  "nephritis"  as  used  in  connection  with 
tuberculosis  may  mean  a  tuberculous  lesion  engrafted  on  an  old 
nephritis,  amyloid  disease,  or  a  true  tuberculous  nephritis.  In  the 
latter  condition,  Reitter^  found  actual  hypotonia  as  contrasted 
with  other  forms  of  pyelitis  and  pyelonephritis  in  which  the  pressure 
w^as  at  least  normal  if  not  distinctly  increased. 

The  vasomotor  instability  of  tuberculosis  is  shown  by  the  fact 
that  at  least  a  large  proportion  of  the  advanced  cases  show  a  fall 
of  pressure  and  a  considerable  increase  in  pulse  rate,  on  changing 
from  the  recumbent  to  the  erect  position. 

Bouchard,  Arloing,  Rhodet,  and  Courmount  believe  that  the 
toxin  of  the  tubercle  bacillus  possesses  distinct  vasomotor  influ- 
ences. These  results  have  been  corroborated  and  much  more  satis- 
factorily demonstrated  by  Emerson.  Man  is  apparently  much 
less  sensitive  to  this  effect  than  animals,  since  a  relatively  larger 
and  more  concentrated  dose  is  required  to  produce  much  fall  of 
pressure.  Whether  this  toxin  is  the  sole  cause  of  the  hypotension 
is  still  undecided.  For  instance,  it  may  result  simply  from  tachy- 
cardia, for  beyond  a  certain  point  systolic  output  falls  with  an 
increasing  pulse  rate,  owing  to  insufficient  diastolic  inflow. 

"  Fever  will  cause  rapid  heart  action  by  its  effect  on  the  accelerans 
nerve  endings  in  the  heart.  Diminished  general  pressure  results 
in  lower  cerebral  pressure,  which  of  itself  stimulates  the  cerebral 
origin  of  cardiac  sympathetic  nerves,  especially  when  the  low 
pressure  is  due  to  vasoparesis"  (Krehl). 

Laryngeal  and  intestinal  complications  are  often  associated  with 
low  pressures.  Arrested  cases  may  show  a  rise,  and  relapsing  cases 
a  fall  of  tension.  Ambulant  patients  yield  higher  readings  than 
bed-fast  cases. 

There  are  three  theories  which  have  been  used  to  explain  the 
toxic  hypotension  of  tuberculosis : 

1.  That  it  is  due  directly  and  chiefly  to  the  heart  muscle,  which 
is  pathologically  altered,  either  as  the  result  of  the  toxins  of  the 
bacillus  or  as  the  result  of  malnutrition. 

2.  That  the  bloodvessels  are  primarily  the  cause  of  the  vaso- 
dilatation, which  is  the  result  of  the  tuberculous  toxins. 

'  Nierentuberkulose  u.  arterielle  Hypotension,  Ztschr.  f.  klin.  Med.,  1907,  Ixii,  358. 


TUBERCULOSIS  225 

3.  That  the  nervous  control  of  both  heart  and  bloodvessels  is 
essentially  influenced  by  the  toxemia,  both  the  vascular  dilatation 
and  the  tachycardia  being  of  nervous  origin. 

Two  practical  facts  present  themselves : 

First.  Is  the  study  of  pulse  and  blood-pressure  of  prognostic  or 
therapeutic  value,  and  is  it  of  diagnostic  value  previous  to  the 
time  when  a  diagnosis  may  be  made  from  physical  signs? 

Second.  To  what  is  the  hypotension  due,  and  to  what  extent 
can  it  be  remedied  by  treatment? 

There  are  wide  diversities  of  opinion  on  these  subjects.  Broadly 
speaking,  the  French  writers  maintain  that  hypotension  is  a  valu- 
able early  sign  of  tuberculosis,  which  may  often  be  suspected  on 
this  account,  even  when  latent;  and  further,  that  it  is  a  valuable 
differential  point  in  deciding  between  chlorosis,  etc.,  and  incipient 
tuberculosis,  also  in  diagnosticating  between  tuberculous  effusions 
in  the  pleura  and  in  the  peritoneum  and  non-tuberculous  effusions. 
On  the  other  hand,  a  large  number  of  observers,  of  whom  many 
are  Germans,  find  that  hypotension  is  inconstant,  and  when  present 
only  a  late  phenomenon.  We  agree  essentially  with  the  latter 
proposition,  feeling  that  the  stethoscope  is  a  far  better  early  diag- 
nostic instrument  than  the  sphygmomanometer,  believing,  how- 
ever, that  blood-pressure  observations  are  capable  of  rendering 
useful  data  so  far  as  the  corroboration  of  diagnosis,  the  gauging  of 
toxemia,  the  permitting  of  exercise,  and  the  recognition  of  relapses 
are  concerned.  It  is  to  be  borne  in  mind,  however,  that  there  is  a 
common  type  of  constitutional  hypotensive  individual  who  has  a 
low  pressure  without  either  active  or  latent  tuberculous  disease 
(see  Essential  Hypotension). 

As  to  the  actual  causes  of  tuberculous  hypotension,  Haven 
Emerson,'  who  has  published  an  excellent  clinical  and  experimental 
study  on  the  subject,  arrives  at  the  following  conclusions: 

"The  causes  of  low  blood-pressure  in  tuberculosis  are  probably 
primarily  a  toxic  action  on  the  vasomotor  centre  in  the  medulla, 
allowing  of  a  vasoparesis  or  stimulating  an  active  vasodilatation, 
and,  secondarily,  progressive  cardiac  atrophy  or  degeneration. 
Toxic  action  on  the  vasomotor  nerves  or  their  motor  terminals  or 
on  the  nervous  mechanism  of  the  heart  cannot  be  positively  denied, 
although  there  is  no  proof  of  it  at  present.  Toxic  action  of  tubercle 
products  has  not  been  demonstrated  on  the  muscle  of  the  vessel 
wall  or  heart,  although  with  regard  to  the  latter,  the  degenerated 

'  Blood-pressure  in  Tuberculosis,  Arch.  Int.  Med.,  1911,  vii  (bibliography). 
15 


226     BLOOD-PRESSURE  IN  CHRONIC  INFECTIO US  DISEASE 

heart  muscle  found  in  advanced  cases  may  have  an  influence  in 
causing  hypotension.  Rapid  heart  action  is  a  usual  and  necessary 
sequel  to  low  blood-pressure,  and  will,  if  extreme,  aggravate  the 
hypotension  by  the  very  act  of  its  shortened  diastole.  It  has 
been  suggested,  but  not  proved,' that  lack  of  vagus  inhibition,  owing 
to  pressure  by  enlarged  bronchial  lymph  nodes  and  the  presence  of 
sympathetic  excitation  from  similar  or  reflex  causes,  such  as  pul- 
monary or  gastric  irritation,  is  responsible  for  the  tachycardia 
and  hypotension. 

"Hypotension  or  subnormal  blood-pressure  is  universally  found 
in  advanced  pulmonary  tuberculosis,  in  which  condition  emaciation 
may  be  responsible  for  its  causation. 

"Hypotension,  when  it  is  present  in  tuberculosis,  increases  with 
an  extension  of  the  process.  Recovery  from  hypotension  accom- 
panies arrest  or  improvement.  Return  to  a  normal  pressure  is 
commonly  found  in  those  who  are  cured.  Continuation  of  hypo- 
tension seems  never  to  accompany  improvement. 

"Displacement  of  the  heart,  which  is  so  common  a  result  of 
retracted  lung  tissue,  or  loss  of  expansion  due  to  cavity  formation 
or  adhesive  pleurisy,  is  spoken  of  as  a  cause  of  tachycardia  accom- 
panying hypotension,  and  it  certainly  seems  to  be  a  contributory 
cause  in  some  cases." 

The  question  whether  hemoptysis  is  associated  with  increased 
blood-pressure  has  received  both  affirmation  and  denial.  Nor  is 
this  surprising  when  we  remember  that  the  pressures  in  the  pulmo- 
nary and  in  the  systemic  circulation  vary  independently  of  each 
other.  A  progressive  diminution  of  the  pulse-pressure  indicates 
continued  hemorrhage.  At.  the  time  of  actual  hemorrhage  the 
excitement  incidental  thereto  tends  to  increase  blood-pressure. 
There  appears  to  be  no  ground  to  support  the  contention  that 
hemorrhage  occurs  most  frequently  in  cases  with  a  high  systolic 
pressure.  The  establishment  of  an  artificial  pneumothorax  is  like- 
wise without  any  constant  influence  on  arterial  tension.^  In  one 
of  Smith's  cases  there  was  a  marked  unilateral  pressure  difference 
associated  with  incomplete  collapse  of  the  lung  due  to  pleural 
adhesions.     (See  Pneumothorax.) 

Blood-pressure  estimations  have  been  used  as  a  gauge  whereby 
to  control  exercise  in  the  tuberculous.  Peters^  decreases  the  amount 
of  exercise  if  the  patient  shows  a  drop  of  6  mm.  or  more  after  one 

'  Smith,  F.  C:     The  Effect  of  Altitude  on  Blood-pressure,  .Jour.  Am.  Med.  Assn., 
1915,  Ixiv,  1812. 
'  '  Blood-pressure  Control  of  Exercise  in  Tuberculosis,  Colorado  Med.,  1915,  vol.  xii. 


TUBERCULOSIS  227 

hour's  rest,  or  if  exertion  is  immediately  followed  by  a  marked  fall 
(10  to  20  mm.)  of  pressure. 

The  Treatment  of  Pulmonary  Hemorrhage. — Both  clinically  and 
experimentally,  hemorrhages  from  the  pulmonary  vessels  tend  to 
cease  spontaneously,  owing  to  the  low  blood-pressure  in  the  pul- 
monary circuit  and  to  the  reticulated  nature  of  the  lung  paren- 
chyma. In  animals  it  is  difficult  to  produce  a  fatal  result,  even 
when  the  main  branch  of  a  lobe  is  cut.  The  protective  mechanism 
in  man  seems  to  be  less  efficient.  The  great  discrepancy  which 
exists  regarding  methods  of  treatment  is  due  to  the  fact  that  a 
distinction  is  not  made  between  the  early  and  late  stages  of  hem- 
orrhage in  which  the  physiological  principles  in  therapeusis  are 
radically  different.  Digitalis,  atropin,  the  nitrites,  aconite,  chloral, 
chloroform,  ergot,  adrenalin,  pituitrin,  and  other  substances,  have 
been  recommended. 

We  have  to  consider  (1)  the  effect  of  the  drug  on  the  pulmonary 
and  (2)  on  the  general  arterial  blood-pressures;  (3)  its  effect  on  the 
small  pulmonary  arterioles;  (4)  its  effect  on  heart  rate  and  systolic 
output;  (5)  its  effect  on  the  respiratory  centre.  Generally  speaking, 
a  reduction  of  pulmonary  pressure  should  reduce  hemorrhage,  but 
if  this  is  done  at  the  cost  of  an  increased  systolic  output  it  will,  of 
course,  not  do  so.  Constriction  of  the  small  pulmonary  vessels  tends 
to  increase  pressure  in  the  pulmonary  arteries  and  thus  to  increase 
bleeding.  It  is  evident,  therefore,  that  the  ability  to  constrict  the 
pulmonary  vessels  is  not  a  criterion  of  its  hemostatic  value.  The 
maintenance  of  a  normal  mean  pressure  in  the  pulmonary  circuit 
is  a  function  which  Nature  tends  to  accomplish  in  spite  of  inter- 
ference, just  as  it  does  in  the  case  of  cerebral  anemia.  Because  we 
lower  the  systemic  pressure,  it  of  course  does  not  follow  that  we 
lower  the  pulmonary  pressure.  Furthermore,  in  the  late  stages  of 
bleeding,  cerebral  anemia  is  prevented  by  splanchnic  vasoconstric- 
tion. To  thwart  this  result  might  produce  death,  which  is  cer- 
tainly a  strong  argument  against  the  use  of  the  nitrites.  What  we 
are  attempting  to  accomplish,  is  to  reduce  pressure  in  or  reflux 
from  the  pulmonary  vessels  without  embarrassing  the  respiratory 
or  vasomotor  centres  or  the  heart  in  their  efforts  to  maintain  the 
circulation. 

The  Physiological  Effect  of  Certain  Drugs  nyon  the  Pulmonary  and 
Systemic  Circulations. — Digitalis  (without  alcohol)  produces  a  rise 
of  pulmonary  pressure,  slight  at  first,  but  increasing  as  its  action 
becomes  more  pronounced.  It  therefore  increases  hemorrhage  by 
augmenting  the  systolic  output  of  the  right  ventricle  and  constrict- 
ing the  pulmonary  vessels. 


228    BLOOD-PRESS URE  IN  CHRONIC  INFECT  10 US  DISEASE 

Ergot  primarily  decreases  pulmonary  arterial  pressure  by  depress- 
ing the  heart.  It  is  followed,  especially  in  normal  animals,  by  an 
increase  due  to  a  secondary  augmentation  of  the  beat.  Pressure 
in  hemorrhage  in  the  pulmonary  veins  is  permanently  increased  at 
the  constriction  of  the  small  vessels.  The  action  of  the  drug  wanes 
as  the  loss  of  blood  continues. 

Pituitrin. — This  drug  has  been  highly  recommended  by  Wiggers, 
since  it  elevates  the  systemic  arterial  pressure  through  vasocon- 
striction in  spite  of  weakening  of  the  left  heart.  The  decrease  in 
amplitude  of  contraction  of  the  right  ventricle  causes  a  fall  of  pul- 
monary pressure,  which  neither  the  weak  constricting  influence  of 
the  blood  on  these  vessels  nor  the  backing  up  of  the  blood  from  the 
left  heart  counteracts.  It  does  not  affect  the  respiratory  centre. 
These  results  occur  both  in  normal  and  in  bleeding  animals. 

Chloroform  produces  a  fall  of  pressure  in  the  pulmonary  circuit 
due  to  depression  of  the  heart  and  aided  by  diminished  respiration. 
During  dyspnea  in  hemorrhage  small  doses  lessen  the  respiratory 
movements  and  so  decrease  pulmonary  pressure  and  hemorrhage, 
while  large  doses  act  similarly  through  cardiac  depression. 

The  Nitrites. — In  normal-breathing  animals  a  general  increase 
in  pulmonary  pressure  is  noted,  due  to  increased  rate  and  systolic 
output  of  the  heart.  In  animals  breathing  rapidly  from  hemorrhage, 
nitrites  increase  both  pressure  and  hemorrhage  from  pulmonary 
arteries  and  veins.  In  the  stage  in  which  the  nitrites  reduce  the 
amplitude  of  respiration  a  lowering  of  the  pulmonary  pressure  and 
a  reduction  of  hemorrhage  occurs. 

Effect  of  Various  Agents  on  Systemic  Pressure,  Respiration,  Pulmonary 

Arterial  Pressure  and  Hemorrhage,  and  Pulmonary  Venous 

Pressure  and  Hemorrhage.     (Wiggers.) 

Pulmonary  Pulmonary 

arterial  venous 

Systemic                                      pressure  and  pressure  and 

Drugs.                                      pressure.          Respiration.       hemorrhage.  hemorrhage. 
Digitalis : 

Normal +                       0                        +  (-)  + 

Hemorrhage    .      .      .       .      +                       0                        +  + 
Strophanthin : 

_      Normal         \  .0  4-4- 

t      Hemorrhage/        ■      •      •      -r                                              -r  -r 
Ergo  toxin : 

Normal +                       —                     1-  — 

Hemorrhage   ....      0             .          —                      0  0 
Pituitary: 

Normal +                       0               -  or  ( +)  -  - 

Hemorrhage    .      .       .      .      +                       —                       —  — 
Chloroform : 

Normal         \                          _                      _                      _  _ 
Hemorrhage/ 
Nitrites: 

Normal -                       0                        +  + 

Hemorrhages,  early  .      .       —                       +                   (— )+  ( — )  + 

Late —                       —                       —  — 


PLEURAL  EFFUSIONS  229 

It  is  essential  in  the  treatment  of  hemoptysis,  as  was  shown  by 
Wiggers^  (from  whose  articles  many  of  the  foregoing  data  were 
taken),  to  differentiate  between  the  early  and  the  late  stages  of  the 
hemorrhagic  process. 

Summary. — In  the  early  stage  of  hemorrhage,  in  a  practically 
normal  subject  with  only  occasional  coughing,  pulmonary  pressure 
should  be  reduced  by  means  of  cardiac  depressants,  chloroform,  or 
pituitary  extract.  The  nitrites  are  contra-indicated.  In  the  late 
stages,  with  tachycardia  and  tachypnea,  the  heart  and  bloodvessels 
no  longer  react  in  a  typical  manner  to  certain  drugs.  Cerebral 
anemia  manifests  itself.  The  blood  supply  of  the  brain  must  be 
maintained.  According  to  Wiggers,  the  only  drug  which  can  ele- 
vate the  systemic  pressure  and  simultaneously  lower  the  pulmonary 
pressure  is  pituitary  extract. 

All  clinical  and  most  experimental  evidence  indicates  that 
morphin  is  the  most  valuable  drug  we  possess  in  the  treatment  of 
hemoptysis.  Fear  and  excitement  are  among  the  most  potent 
causes  of  increased  arterial  tension  in  general,  and  probably  in  the 
pulmonary  circulation,  and  under  these  conditions  nervous  sedatives 
are  the  most  rational  form  of  therapy. 

Recent  experiments,  however,  show  that  morphin  may  be  harm- 
ful when  death  is  threatened  by  a  hemorrhagic  fall  of  pressure. 
There  are  two  factors  to  be  considered:  (1)  Augmented  breathing 
acts  favorably  from  a  mechanical  point  of  view  in  maintaining 
blood-pressure.  (2)  Excessive  breathing  may  produce  acapnia  and 
cause  a  fall  of  blood-pressure.  Wiggers^  maintains  that  the  former 
condition  outweighs  the  latter  in  importance,  and  that  morphin 
must  be  employed  with  caution.  This  statement,  of  course,  applies 
only  in  the  case  of  large  hemorrhages  in  which  death  is  to  be  feared, 
and  the  evidence  furnished  cannot  be  used  to  negative  the  well- 
attested  clinical  results  which  have  shown  the  good  effects  of 
morphin. 

Pleural  Effusions. — The  existence  of  pleural  and  peritoneal  eft'u- 
sions,  especially  if  large,  tend  to  increase  blood-pressure,  and  their 
removal  is  attended  with  a  fall  of  arterial  tension.  The  pressure, 
therefore,  of  such  serous  effusions  may  increase  a  pressure  already 
high  as  the  result  of  nephritis,  and  a  fall  of  pressure  following 
aspiration  may  not  indicate  any  improvement  in  the  basic  condition 


*  A  Physiological  Investigation  of  the  Treatment  of  Hemoptysis,  Arch.  Int.  Med., 
July  15,  1911;    Studies  in  Inaccessible  Internal  Hemorrhages,  Ibid.,  March,  1909. 

*  Wiggers,  C.  J.,  Eberly,  K.  C,  and  Wenner,  H.  L. :     The  Pressor  Influence  of 
Augmented  Breathing,  Jour.  Exp.  Med.,  1912,  p.  174. 


230    BLOOD-PRESS  URE  IN  CHRONIC  INFECT  10  US  DISEASE 

from  which  the  patient  suffers.  On  the  other  hand,  a  cardiac 
hydrothorax  may  cause  a  pressure  sufficiently  high  to  make  one 
suspect  a  coincident  nephritis  when  no  such  compHcation  exists. 

The  emotional  disturbance  entailed  by  a  prospective  operation  as 
well  as  the  actual  pain  of  puncture  produce  a  temporary  elevation 
of  blood-pressure.  Aspiration  of  a  pleural  exudate  is  attended  by 
a  gradual  fall  of  blood-pressure  which  occurs  pari  passu  with  the 
withdrawal  of  fluid.  According  to  Capps,^  a  fall  of  20  mm.  is 
usual.  The  systolic  pressure  is  chiefly  affected.  This  fall  of  pressure 
is  probably  not  merely  the  result  of  the  mechanical  pressure  effects, 
but  is  in  part  due  to  vasodilator  and  cardio-inhibitory  reflexes. 

After  withdrawal  there  is  a  gradual  rise  of  pressure,  but  the 
initial  limit  may  not  be  reached  for  some  time.  The  rate  of  with- 
drawal is  no  less  important  than  the  amount  of  fluid  removed  in  its 
effect  on  the  immediate  fall  of  pressure.  The  more  long  standing 
the  effusion  the  greater  the  fall  of  pressure,  probably  due  to  imper- 
fect pulmonary  expansion.  Marked  reactions  and  a  slow  recovery 
are  seen  in  arteriosclerotic  cases. 

By  observing  the  blood-pressure  during  thoracentesis,  untoward 
effects  such  as  weakness,  vertigo  or  collapse,  symptoms  which 
often  occur  suddenly  and  without  warning,  may  be  anticipated 
and  obviated.     (See  Aspiration  of  the  Pleura,  page  406.) 

Pneumothorax. — Pneumothorax  and  penetrating  wounds  of  the 
chest,  in  addition  to  well-known  symptoms,  are  often  associated 
with  bradycardia  and  a  rise  of  blood-pressure  (presenting  some- 
times an  analogy  to  cerebral  injuries),  from  which  signs  too  opti- 
mistic conclusions  may  easily  be  drawn. 

Experimental  Data.— The  reports  to  be  found  in  literature  on 
blood-pressure  in  artificial  pneumothorax  are  very  divergent. 
Kakowski^  and  others  report  a  rise  in  open  pneumothoraces, 
other  investigators  no  change,  and  still  others  a  fall  of  blood- 
pressure. 

According  to  Walther  experimental  pneumothorax  in  the  normally 
breathing  rabbit  is  associated  with  a  slowing  and  an  increase  in 
the  volume  of  the  pulse.  Pvlimination  of  vagus  control  does  not 
check  the  rise  of  pressure  which  is  apparently  due  to  CO2  stimulation 
of  the  vasomotor  centre.  The  change  in  the  pulse  rate,  on  the 
other  hand,  is  believed  to  result  from  vagus  stimulation.  The 
difference  in  response  between  an  open  and  a  closed  pneumothorax, 

1  Observations  on  the  Effect  on  the  Blood-pressure  of  Withdrawal  of  Fluid  from 
the  Thorax  and  Abdomen,  Jour.  Am.  Med.  Assn.,  January  5,  1907,  xlviii. 

'  Zur  Frage  d.  Kiinstlicheu  Pneumothorax,  Pfliiger's  Arch.,  1910,  cxxxiv,  31. 


PNEUMOTHORAX  231 

which  is  only  one  of  degree,  has  been  explained  as  due  to  the  fact 
that  in  the  latter,  in  addition  to  stimuli  which  result  from  pleural 
irritation,  those  arising  in  the  bronchial  mucous  membrane  (since 
respiratory  excursions  are  still  present)  are  superadded.  The  irri- 
tation of  the  pleura  is  conducted  by  the  sensory  fibers  of  the  vagus 
to  the  nucleus  and  produces  increased  vagus  tone.^ 

Clinical  Data. — Spontaneous  pneumothorax  may  come  on  sud- 
denly with  acute  pain  and  shock,  especially  if  the  onset  occurs 
during  exercise  in  apparently  healthy  individuals.  Frequently, 
however,  pneumothorax  occurs  insidiously^  during  the  course  of 
tuberculosis.  In  the  former  instance  a  primary  fall  of  blood- 
pressure  is  succeeded  by  a  rise  to  above  the  normal,  which  is  in 
part  at  least  the  result  of  anxiety,  pain,  and  asphyxia.  In  the  latter 
instance  blood-pressure  changes  are  neither  constant  nor  marked, 
especially  if  only  a  partial  pneumothorax  is  present. 

There  is  considerable  reason  to  believe  that  the  occurrence  of 
pneumothorax  in  the  course  of  tuberculosis  may  have  beneficial 
effects.  Certainly  the  artificial  production  of  this  condition  is 
often  attended  with  marked  symptomatic  improvement.  Just 
to  what  extent  this  is  due  to  changes  in  the  pulmonary  circulation 
is  as  yet  uncertain.  "It  is  disputable  as  to  whether  the  contracted 
lung  contains  more  or  less  venous  blood.  In  fact,  there  is  experi- 
mental evidence  that  the  pulmonary  circulation  adapts  itself 
promptly  to  the  change  and  is  therefore  not  particularly  disturbed."' 

The  immediate  effects  of  artificial  pneumothorax  are  variable,  but 
once  established,  the  collapsed  lung  and  increased  intrathoracic 
pressure  have  little  or  no  effect  upon  arterial  pressure.'*  The  symp- 
toms of  shock,  and  occasionally  sudden  death  have  followed  this 
procedure.  Such  events  are  generally  due  to  a  pleural  reflex  which 
consists  of  afferent  medullary  impulses  by  way  of  the  vagus  nerve 
from  its  terminal  filaments,  which  have  been  rendered  unduly 
susceptible  to  stimuli  as  a  result  of  compression  or  inflammation. 
Death  is  apparently  due  to  vasoconstriction  of  the  cardiac  or 
cerebral  vessels.  Artificial  pneumothorax  should  never  be  employed 
in  the  presence  of  severe  cardiac  complications.* 

'  Walther,  H.  E.:  Zur  Kentniss  der  Puis  u.  Blutdruckveranderungen  beim 
Pneumothorax,  Deutsch  Ztschr.  f.  Chir.,  1912,  cxix,  253. 

*  "Among  500  cases  of  pneumothorax  the  onset  was  sudden  in  77  and  insidious  in 
23  per  cent,  of  the  cases.  The  latter  class  was  evidently  underestimated."  Pepper, 
O.  H.  P.:     Am.  Jour.  Med.  Sc,  October,  1911. 

'  Robinson,  S.,  and  Floyd,  C. :  Artificial  Pneumothorax  as  a  Treatment  of  Pul- 
monary Tuberculosis,   Arch.   Int.    Med.,    1912,   ix,   452. 

*  Smith,  F.  C:  Effects  of  Altitude  on  Blood-pressure,  Jour.  Am.  Med.  Assn., 
1915,  Ixiv,  1812. 

'  Sachs, T.  B.:  Artificial  Pneumothorax  in  the  Treatment  of  Pulmonary  Tuber- 
culosis, Jour.  Am.  Med.  Assn.,  1915,  Ixv,  18G1. 


CHAPTER  IX. 

EXOGENOUS  INTOXICATIONS. 

Lead  Poisoning. — The  most  important  exogenous  intoxication, 
so  far  as  blood-pressure  is  concerned,  is  lead  poisoning.  Hyper- 
tension is  produced  directly  as  the  result  of  plumbism  and  indirectly 
as  a  result  of  gout,  nephritis,  or  arteriosclerosis,^  with  each  of 
which  conditions  plumbism  is  closely  allied.  The  onset  of  both 
lead  colic  and  encephalopathy  is  associated  with  marked  exacerba- 
tions of  pressure  even  in  the  absence  of  nephritis  or  gross  vascular 
lesions.  This  increase  in  pressure  is  believed  to  be  the  result  of 
vascular  spasm,  since  it  disappears  after  the  paroxysm.  The  arterial 
constriction  is  evident  on  examination  of  the  retinal  vessels;  and 
Pal  has  reported  a  case  of  lead  amaurosis  which  appeared  with 
the  onset  and  disappeared  with  the  abeyance  of  hypertension. 
The  systolic  pressure  is  chiefly  affected,  and  large  as  well  as  sudden 
variations  of  pressure  are  often  encountered.  Extended  observa- 
tions have  shown  that  80  per  cent,  of  all  lead-workers  exhibit  high 
arterial  pressure  over  years  of  time  even  when  free  from  symptoms 
of  poisoning,  a  fact  which  might  be  expected  if  the  contention  of 
Schmidt,-  be  correct  that  no  real  elimination  of  lead  ever  occurs, 
once  it  has  entered  the  body,  but  merely  a  transference  of  it  to 
different  tissues.  Most  but  not  all  cases  of  colic  show  an  exacerba- 
tion of  tension  coincidently  with  the  colic.  The  actual  pressure 
does  not  generally  exceed  200  mm.  Hg.,  except  in  cases  of  enceph- 
alopathy. It  seems  eminently  likely  that  the  pain  markedly 
augments  the  pressure.  But  that  pain  is  not  the  essential  cause 
is  shown  by  the  fact  that  lowering  of  pressure  relieves  it,  while 
relief  of  the  pain  with  morphin  does  not  lower  the  tension,  nor  does 
pressure  always  fall  with  a  spontaneous  relief  from  colic.  It  has,  on 
the  other  hand,  been  maintained  that  the  pressure  is  compensatory, 
and  when  sufficiently  high  prevents  the  colic.  The  latter  view  does 
not  commend  itself.     The  hypertension  has  also  been  attributed 

'  The  vascular  changes  differ  from  those  of  ordinary  arteriosclerosis.  The  vessels 
do  not  collapse  and  exhibit  a  normal  intima  with  marked  hypertrophy  of  the  media. 
Cardiac  hypertrophy  is  not  constant. 

^  Untersuchungen  bei  experimenteller  Bleivergiftiing,  Deutsch.  Arch.  f.  klin.  Med., 
1909,  xcvi,  587. 


LEAD  POISONING  233 

to  the  effect  of  lead  on  the  central  nervous  system.  It  has  also 
been  suggested  that  the  hypertension  is  due  to  increased  adrenal 
secretion.  Heubel^  maintains  that  the  rise  of  pressure  is  purely 
secondary  to  nephritis,  etc.;  while  Broadbent  attributes  it  to  the 
chemical  formation  of  lead  albuminates,  which,  being  with  difficulty 
broken  down,  complicate  metabolic  changes  and  render  the  elimi- 
nation of  metabolites  difficult.  Menetrier  and  others  believe  that 
arterial  hypertension  is  a  primary  and  initial  toxic  phenomenon. 

Lead  colic  is  generally  regarded  as  due  to  involvement  of  the 
solar  plexus.  Thus,  Laignel-Lavastine  speaks  of  the  pain,  con- 
stipation, and  hypertension  as  symptoms  of  "solar  stimulation." 
Lesions  of  the  ganglia  of  the  plexus  have  been  demonstrated  post- 
mortem (Tanquerel,  Kussmaul,  Maier)  and  experimentally  (Mosse). 

Experimental  Data. — The  intravenous  injection  of  lead  salts 
produces  arterial  hypertension.  Of  course  it  does  not  follow 
because  acute  intoxication  produces  this  effect  that  therefore 
chronic  poisoning  will  have  similar  results.  The  chief  physiological 
action  of  lead  is  exerted  on  striated  muscle,  in  which  it  produces  a 
diminished  functionation  (Nothnagel  and  Ilossbach).  This  would 
lead  to  vasomotor  relaxation  and,  unless  it  were  counter-balanced 
by  compensatory  vasoconstriction,  to  a  fall  of  pressure.  According 
to  Jores,^  such  a  relaxation  occurs  in  the  smaller  arteries  of  rabbits 
poisoned  with  lead. 

Clinical  Data. — Hypertension  has  long  been  observed  clinically. 
The  presence  of  hypertension,  especially  if  nephritis  can  be  elimi- 
nated, should  certainly  suggest  the  possibility  of  plumbisra  even  if 
the  gingival  blue  line  or  basophilic  degeneration  of  the  erythrocytes 
cannot  be  demonstrated.  Arterial  stasis  alone  will  not  increase 
pressure,  and  since  there  is  a  marked  hypertension  during  attacks 
of  colic,  we  must  assume  a  vasoconstriction,  either  as  the  result  of 
a  toxic  effect  or  owing  to  some  compensatory  antagonistic  physio- 
logical action  (central  vasoconstriction?). 

Furthermore,  as  shown  by  Hasebroek,  the  sphygmograph  of  a 
lead  pulse  is  more  like  that  of  a  normal  pulse  than  that  of  an  arterial 
hypertension.  He  uses  this  and  some  of  the  foregoing  arguments 
to  establish  the  existence  of  an  active  arterial  diastole,  and  believes 
that  plumbic  hypertension  results  not  from  vascular  spasm  but  from 
an  "  increased  activity  of  the  pressor  components  of  physiological 
vascular  functionation."    Stewart  in  his  studies  on  blood  flow  found 

*  Path.  u.  Synipt.  der  chr.  BleivcrgiftuiiK,  Berlin. 

-  Uebcr  die  path.  Anat.  d.  chronischen  BleivergiftuuR  des  Kaiiincheiis,  Miinchcn. 
med.  Wehnsehr.,  1902,  p.  713. 


234  EXOGENOUS  INTOXICATIONS 

in  lead  poisoning  without  paralysis  a  conspicuous  tendency  to  reflex 
vasoconstriction. 

Well-marked  bradycardia  is  quite  common.  In  1179  cases  Tan- 
querel  found  the  pulse  rate  between  20  and  60  in  678,  between 
65  and  70  in  376,  and  between  80  and  100  in  125  cases.  Such  cases 
are  a  true  bradycardia  due,  it  appears,  to  a  toxic  effect  upon  the 
vagus  nerve  or  its  terminations.  The  bradycardia  and  the  arterial 
hypertension  are  independent  phenomena.^ 

Encephalopathy. — In  this  condition  very  high  pressures  are  often 
encountered.  Menetrier^  attributes  the  symptoms  to  the  high 
pressure. 

In  a  man,  aged  twenty-one  years,  during  one  of  many  attacks 
of  colic,  a  pressure  of  260  mm.  was  found  which  soon  reached  300 
mm,  and  was  then  associated  with  marked  cerebral  symptoms. 
At  autopsy  the  kidneys  were  normal,  as  had  been  the  urinary  find- 
ings during  life.  The  brain  showed  marked  signs  of  pressure, 
edema,  distended  membranes,  flattened  convolutions,  etc. 

It  appears,  therefore,  that  plumbism  may  be  accompanied  by 
numerous  clinical  manifestations  which  strongly  suggest  vascular 
spasm  as  the  basis  of  their  production.  Thus  the  abdominal  colic, 
anginoid  attacks,  encephalopathy,  including  amaurosis,  hemianopia, 
aphasia,  deafness,  etc.,  have  been  attributed  to  local  vascular 
contraction. 

Although  generally  associated  there  is  no  absolute  parallelism 
between  pain  and  vascular  spasm;  either  may  exist  without  the 
other.  It  is  not  yet  proved  that  lead  colic  is  due  (1)  to  spasm  of 
intestines  or  to  (2)  spasm  of  mesenteric  arteries.  It  is  apparently 
associated  with  a  general  vascular  spasm  in  which,  of  course,  the 
splanchnics  have  a  part.  Such  a  general  contraction  may  begin 
suddenly  or  gradually,  hence  it  is  often  difficult  to  say  what  the 
individual's  normal  is.  The  fact  that  pain  is  absent  is  no  proof  that 
the  vessels  are  not  contracted.  Hypotension  (55  to  75  mm.  Ilg.) 
may  follow  colicky  attacks.  Relief  from  constipation  often  goes 
hand  in  hand  with  the  disappearance  of  pain  and  with  a  fall  of 
pressure  (Riegel). 

With  so  many  divergent  theories  and  such  equivocal  experi- 
mental and  clinical  findings,  we  must  conclude  by  saying  that 
although  in  lead  poisoning  hypertension  is  constant,  and  exacer- 
bations of  tension  frequent,  we  are  still  unable  to  make  positive 
statement  as  to  the  exact  mechanism  by  virtue  of  which  these 

1  Lion  and  Marcorelles:    Presse  M6d.,  1913,  No.  12,  p.  109. 
^  Soc.  m^d.  des  Hopitaux,  February  12,  1904. 


TOBACCO  235 

vascular  phenomena  are  produced,  or  whether  they  are  primary  or 
secondary-  manifestations.  Persistent  marked  hypertension  is  of 
bad  augury  in  plumbism.  Borgen  has  observed  the  following 
phenomena  in  cases  of  lead  colic:  (1)  period  of  rising  pressure,  of 
variable  duration;  (2)  period  of  high  pressure,  one  to  four  days; 
either  of  the  above  may  be  associated  with  colic;  (3)  period  of 
decrease,  two  to  four  days,  with  disappearance  of  symptoms;  (4) 
period  of  subnormal  pressure  (95  mm.). 

Therapeutics. — If  the  conception  of  the  pathological  process  as  a 
local  (or  general)  vascular  spasm  is  correct  then  purgation  with 
salines  and  belladonna  is  a  rational  procedure.  The  administration 
of  morphin  is  purely  palliative.  Pal  endorses  the  custom  sanc- 
tioned—administration of  the  iodides  in  large  doses — saying  that 
symptoms  of  lead  colic  cease  as  soon  as  those  of  iodism  appear. 
Some  researches  have  thrown  doubt  upon  the  efficacy  of  the  iodides, 
at  least  so  far  as  elimination  is  concerned,  and  have  suggested  the 
employment  of  bile  salts.  The  administration  of  the  nitrites  in 
large  doses  {-^\  gr.  nitroglycerin  hourly)  sometimes  alleviates  the 
pain  of  lead  colic  promptly  and  permanently.  I  have  observed  this 
fact  on  numerous  occasions. 

Phosphorus. — Acute  phosphorus  poisoning  so  far  as  the  cir- 
culation is  concerned,  produces  a  degeneration  of  the  heart  muscle, 
and  while  this  is  doubtless  a  contributing  factor  in  the  cause  of 
death,  it  appears  from  Pal's  investigations  that  the  primary  cause 
lies  in  a  fall  of  blood-pressure  due  to  loss  of  vasomotor  tone. 

Chlorin  Gas. — ^The  inhalation  of  chlorin  gas  which  has  been  used 
in  trench  warfare  causes  a  marked  fall  in  blood-pressure,  a  slowing 
and  irregularity  of  respiration  and  pulmonary  symptoms  which  are 
apparently  due  to  obstruction  of  the  pulmonary  circulation  rather 
than  to  spasm  occlusion  of  the  bronchioles.^ 

Arsenic. — Acute  arsenical  poisoning  causes  a  fall  of  blood-pressure 
due  to  depression  of  the  heart  and  the  vasomotor  centre. 

Tobacco. — There  has  been  much  discussion  as  to  whether  the 
constitutional  effects  which  follow  the  use  of  tobacco  are  due  to 
nicotin  or  to  other  substances.  The  evidence  at  hand  indicates 
that  nicotin  is  by  far  the  most  important,  if  not  the  sole  factor, 
but  other  substances,  such  as  carbon  monoxid,  hydrocyanic  acid, 
furfural  and  other  aldehyds,  have  also  to  be  reckoned  with. 

Lehman  has  shown  that  the  slower  the  rate  of  smoking  the  smaller 
the  amount  of  hydrocyanic  acid  formed.  This  substance,  however, 
seems  to  be  present  in  too  small  amounts  to  account  for  physio- 

'  Schafer,  E. :  On  the  Immediate  Effects  of  the  Inhalation  of  Chlorin  Clas,  British 
Med.  Jour.,  August  14,  1915,  p.  245. 


236  EXOGENOUS  INTOXICATIONS 

logical  s;^Tiiptoms.  The  ordinary  cheap  cigarettes  (Virginia  tobacco) 
contain  only  a  negligible  quantity  of  nicotin.  They  do,  however, 
contain  a  large  quantity  of  furfural  to  which  the  harmful  effects 
may  be  due,  yet  this  substance  is  practically  absent  from  Turkish 
cigarettes, 1 

Experimental  Data.^ — With  moderate  quantities  of  nicotin  the 
pulse  rate  is  slowed;  the  heart  may  stop  for  a  few  seconds  in  diastole, 
then  gradually  assume  an  accelerated  rhythm.  The  slowing  is  due 
to  stimulation  of  the  vagus  ganglia.  "It  is  not  affected  by  section 
of  the  cervical  pneumogastric,  as  the  path  from  the  ganglia  to  the 
cardiac  ganglia  is  still  intact,  but,  on  the  other  hand,  it  is  prevented 
by  atropin,  which  acts  on  the  extreme  terminations  of  the  inhibitory 
fibers,  and  therefore  blocks  the  passages  of  impulses  from  the 
ganglia  to  the  muscle." 

Nicotin  is  second  only  to  epinephrin  as  a  vasoconstrictor.  Blood- 
pressure  is  increased  owing  partly  to  stimulation  of  the  vasocon- 
strictor centre  in  the  medulla,  biit  chiefly  to  peripheral  influences, 
for  it  occurs  even  after  extirpation  of  the  spinal  cord.  "  The  vaso- 
constrictor nerves  pass  through  ganglia  on  their  way  to  the  vessels, 
and  the  rise  of  blood-pressure  seems  to  be  mainly  caused  by  a  stim- 
ulation of  these  ganglia"  (Cushny).  Hemorrhage  causes  a  marked 
increase  in  the  vasomotor  reaction  to  nicotin.^ 

The  fact  that  on  analysis  a  certain  variety  of  tobacco  is  shown 
to  contain  a  greater  or  a  smaller  quantity  of  nicotin  by  no  means 
proves  that  when  smoked  it  will  yield  an  equivalent  amount.  In 
fact,  the  very  opposite  result  may  be  obtained.  The  nicotin  content 
of  the  smoke  depends  largely  on  the  completeness  and  quickness  of 
combustion.  Ordinarily,  half  of  the  nicotin  is  destroyed  by  com- 
bustion. Of  the  remainder  variable  quantities  reach  the  mouth, 
being  carried  there  by  the  hot  smoke,  which,  in  passing  through  the 
condensation  area,  volatilizes  certain  substances  in  the  tobacco. 
Hence  the  larger  the  condensation  area  (long,  thick  cigars)  the 
greater  the  amount  of  nicotin,  etc.,  which  comes  through. 

The  smoking  of  tobacco  in  the  form  of  cigarettes  is,  for  an  equal 
arnount  of  this  substance  consumed,  less  harmful  than  when  used 
in  the  form  of  cigars  or  a  pipe,  assuming  of  course  that  inhalation 
is  practised  in  each  instance,  because  of  the  more  complete  combus- 
tion which  ensues.  Long  cigars  are  relatively  more  injurious  than 
short  ones  because  they  furnish  a  large  condensation  area  in  which 
the  unconsumed  nicotin  accumulates.  The  last  third  of  the  cigar 
is  therefore  more  toxic  than  the  first  two-thirds.     For  the  same 

>  See  editorial,  Jour.  Am.  Med.  Assn.,  1912,  lix,  1798. 

'  Hoskins,  Rowley  and  Rosser:  Arch.  Int.  Med.,  1915,  xvi,  456. 


TOBACCO  237 

reason  a  cigar  which  has  ceased  to  burn  should  not  be  rehghted.^ 
The  habit  of  holding  an  extinguished  cigar  between  the  lips  should 
not  be  practised.    Long-stemmed  pipes  are  better  than  short  ones. 

Tobacco  and  Arteriosclerosis. — The  importance  of  tobacco  as  an 
etiological  factor  in  arteriosclerosis  has  been  much  discussed  and 
the  question  still  remains  unsettled.  The  tobacco  habit  is  usually 
coupled  with  the  use  of  alcohol  and  frequently  with  faulty  methods 
of  living.  It  has  yet  to  be  shown  that  the  career  of  smokers  is 
shorter  than  that  of  non-smokers.  It  is  admitted  that  tobacco  is  a 
cardiovascular  poison  which  is  at  first  an  excitant  to  the  neuro- 
muscular apparatus,  later  a  motor  nerve  depressant,  and  finally  a 
paralyzant  of  the  cardiac  nerves.  But  whether  it  produces  arterio- 
sclerosis, either  by  its  direct  toxic  action  on  the  vessels  or  indirectly 
by  its  effect  on  blood-pressure,  is  a  very  different  question.  Lee 
apparently  succeeded  in  producing  definite  vascular  lesions  in 
rabbits  which  were  made  to  inhale  tobacco  smoke  over  prolonged 
periods  of  time. 

Clinical  Data. — There  are  of  course  individual  differences,  but 
generally  tobacco  tends  to  raise  both  the  pulse  rate  and  the  blood- 
pressure,  the  former  being  in  part  the  cause  of  the  latter.  These 
effects  often  appear  after  the  first  inhalation  of  smoke,  and  may  be 
accompanied  by  a  sensation  of  nervousness  and  sometimes  pre- 
cordial fulness  or  palpitation.  The  secretion  of  the  adrenals  is 
controlled  by  the  sympathetic  nerve,  which  is  at  first  stimulated 
and  later  depressed  by  the  administration  of  nicotin.^ 

The  elevation  of  blood-pressure  ranges  between  3  and  25  mm., 
the  systolic  pressure  being  chiefly  affected,  indicating  that  the  heart 
is  more  affected  than  the  bloodvessels.  Pressure  generally  falls  to 
or  slightly  below  the  original  level  within  twenty  minutes.  Hesse^ 
found  these  results  more  marked  in  smokers  than  in  non-smokers. 
The  greatest  rise  in  the  pulse  rate  was  twenty-five  beats  per  minute. 
A  return  to  the  normal  occurs  in  from  twenty  to  forty  minutes. 
Excessive  quantities  of  nicotin  cause  a  fall  of  pressure  from  depres- 
sion of  the  vasomotor  cen^tre  and  may  in  this  way  actually  cause 
collapse.  Strong  tobacco  causes  more  marked  effects  than  the 
weaker  varieties  and  in  strongly  reacting  individuals  the  pressure 
may  remain  high  for  two  hours.*    Acute  tobacco  poisoning  causes 

*  Lee,  W^  E. :  The  Action  of  Tobacco  Smoke,  with  Special  Reference  to  Arterial 
Pressure  and  Degeneration,  Quart.  Jour.  Physiol.,  1908,  p.  335. 

2  Cannon,  Aub,  and  Dinger:     A  Note  on  the  Effect  of  Nicotin  Injection  on  Adrenal 
Secretion,  Jour.  Phar.  and  Exp.  Therap.,  1912,  iii,  379. 
'  Deutsch.  Arch.  f.  klin.  Med.,  March  15,  1907. 

*  John,  M.:  Ueber  d.  Beeinflussung  des  systolischcn  u.  diastolischen  Blutdrucks 
durch  Tabakrauchen,  Ztschr.  f.  exp.  Path.  u.  Therap.,  1913,  xiv,  352. 


238  EXOGENOUS  INTOXICATIONS 

a  fall  of  blood-pressure,  associated  with  nausea,  vomiting,  vertigo, 
and  sudation. 

Tobacco,  then,  should  be  forbidden,  or  its  consumption  limited 
when  (1)  we  wish  to  spare  the  heart — cardiac,  renal,  pulmonary 
disease,  etc.;  (2)  in  arterial  hypertension;  (3)  in  arteriosclerosis. 

Chronic  Alcoholism. — Chronic  alcoholism  is  associated  with 
variable  blood-pressure,  depending  upon  the  extent  to  which  renal 
and  cardiovascular  changes  have  occurred.  But  alcoholics  in  whom 
these  organs  are  sound,  show,  when  abstinence  has  been  enforced, 
a  marked  rise  of  the  systolic  pressure  followed  after  a  few  days  by  a 
gradual  fall.  The  diastolic  pressure  is  constantly  high.  Raff^  finds 
these  results  so  constantly  as  to  be  of  diagnostic  value  in  differen- 
tiating between  alcoholism  and  functional  neuroses. 

Delirium  Tremens. — In  the  asthenic  type  of  case  the  systolic 
pressure  is  uniformly  low  and  the  pulse-pressure  small.  A  reestab- 
lishment  of  normal  relations  goes  hand  in  hand  with  the  subsidence 
of  delirium.  This  would  indicate  that  the  height  of  blood-pressure, 
through  its  effect  on  the  cerebral  circulation,  bears  a  causal  relation 
to  the  delirium,  a  statement  which  is  further  borne  out  by  the  fact 
that  if  more  normal  values  can  be  temporarily  established  by  what- 
ever means,  symptomatic  improvement  occurs  (Pettey).^  The 
treatment  of  delirium  tremens  by  means  of  lumbar  puncture  has 
been  attended  by  excellent  results.  It  appears  that  the  delirium 
is  in  part  due  to  increased  cerebrospinal  pressure,  and  in  part  to 
toxicity  of  the  spinal  fluid.  As  pointed  out  elsewhere  there  is  no 
constant  relationship  between  arterial  and  cerebrospinal  pressure. 
(See  Meningitis,  and  Lumbar  Puncture.) 

Hogan^  in  53  cases  of  delirium  tremens  has  reported  systolic 
pressures  ranging  from  95  to  220,  the  average  being  140.  These 
cases  were  treated  by  the  intravenous  administration  of  hypertonic 
alkali  and  also  glucose  dissolved  in  water  and  given  in  large  infu- 
sions. He  found  despite  the  large  amount  of  fluid  infused  and  its 
alkaline  character  blood-pressure  was  reduced  in  the  high-pressure 
cages.  The  rationale  of  this  treatment,  which  appears  to  have  been 
attended  with  a  marked  amelioration  of  symptoms,  is  that  the  hyper- 
tonic solution  dehydrates  the  body  colloids  and  diminishes  edema 
of  the  brain  as  well  as  of  the  other  tissues.* 

'  Bhitdrufkmessungen  bei  Alkoholikern  u.  funktionellen  neurosen  unter  Ausschluss 
von  Kreislaiifstorungen,  Deutsch.  Arch.  f.  klin.  Med.,  1913,  cxii,  209. 

2  The  Narcotic  Drug  Diseases  and  Allied  Ailments,  Philadelphia,  1913,  p.  99. 

'  Treatment  of  Acute  Alcoholic  Delirium,  Jour.  Am.  Med.  As.so.,  1916,  Ixvii,  1826. 

*  In  the  preparation  of  the  solutions  5.8  gnis.  of  chemically  pure  sodium  chloride 
and  8.4  gnis.  of  chemically  pure  sodium  bicarbonate  are  boiled  in  120  c.c.  of  distilled 
water  and  filtered  through  paper,  then  placed  in  a  flask  and  reboiled.  In  addition 
10.2  gnis.  of  chemically  pure  sodium  bromide  is  boiled  in  30  c.c.  distilled  water, 
filtered  and  reboiled.     These  may   be  kept  ready  for    use,  and  when  needed  are 


CARBON  MONOXIDE  POISONING  239 

Morphinism. — ^According  to  Pettey,  morphin  habitues  generally 
show  a  high  pressure  due  largely,  it  seems,  to  portal  congestion, 
since  evacuation  of  the  bowels  often  causes  a  fall  of  from  30  to  60 
mm.  Hg.  "This  reduction  of  arterial  tension  by  the  preparatory 
treatment,  now  universally  verified,  is  an  essential  factor  in  pre- 
venting collapse  and  other  dangerous  complications  during  the 
withdrawal  period." 

Patients  admitted  with  a  blood-pressure  of  180  to  200  mm.  were 
usually  found  to  have  a  blood-pressure  of  140  to  150  after  the  sys- 
tem had  been  cleansed  of  toxic  matter  and  the  drug  withdrawn. 
The  lowered  record  is  maintained  throughout  convalescence,  show- 
ing that  it  was  the  individual's  normal  pressure. 

The  experience  of  the  writer  with  this  class  of  patients  has  been 
limited,  but  he  nevertheless  feels  that  the  preceding  statements 
must  be  accepted  with  reserve.  Certainly,  patients  with  the  opium 
habit  as  seen  in  our  hospitals  are  generally  admitted  in  a  condition 
of  semicollapse,  due  to  starvation,  intoxication,  and  cachexia,  with 
blood-pressure  distinctly  below  the  normal. 

Valenti^  found  that  if  morphin  were  withdrawn  from  dogs  which 
had  become  accustomed  to  its  use,  marked  circulatory  disturbances 
such  as  arterial  hypotension,  arrhythmia  and  tachycardia  occurred. 
These  symptoms  abated  if  the  use  of  the  drug  was  renewed. 
Furthermore,  the  serum  of  dogs  suddenly  deprived  of  morphin 
caused  similar  symptoms  when  injected  into  other  dogs,  whereas 
the  serum  of  unmorphinized  dogs  has  no  such  effect.  It  seems 
evident,  therefore,  that  during  the  withdrawal  stage,  circulation 
stimulation  may  be  necessary. 

Carbon  Monoxide  Poisoning. — In  the  early  stages  of  CO  poisoning 
blood-pressure  rises,  the  pulse  rate  is  increased  and  not  infre- 
quently irregular.  Later  blood-pressure  falls  and  the  cardiac  rate 
alternates  between  bradycardia  and  tachycardia.  Finally,  in  the 
third  stage,  with  a  weak,  thready  pulse,  and  a  leaky  skin,  blood- 
pressure  falls  owing  to  paralysis  of  the  vasomotor  centre.^ 


added  to  850  c.c.  of  either  freshly  distilled  water  or  tap  water  that  has  been  filtered 
and  boiled.  Under  no  circumstances  should  old  distilled  wat«r  be  used,  as  it  may  pro- 
duce severe  chills.     This  mixture  is  heated  to  about  110°  F.  and  is  ready  for  use. 

In  a  flask  with  250  c.c.  distilled  water  80  gms.  of  glucose  are  placed  and  boiled. 
To  this  is  added  0.25  gm.  of  blood  charcoal.  This  is  allowed  to  stand  for  twenty- 
four  hours,  is  then  filtered  into  a  clean  flask,  reboUed,  and  is  ready  for  use.  This 
solution  may  be  made  up  and  kept  ready  for  use. 

Both  of  these  solutions  must  be  given  very  slowly,  from  twenty  to  thirty  minutes 
being  taken  for  the  1250  c.c. 

'  Experimentelle  Untersuchungen  u.  d.  chronischen  Morphinismus,  etc..  Arch.  f. 
exper.  Path.  u.  Pharmakol.,  1914,  Ixxv,  437. 

2  Glaister  and  Logan:  Gas  Poisoning  in  Mining  and  Other  Industries,  Edinburgh, 
1914,  p.  207. 


CHAPTER  X. 
BLOOD-PRESSURE  IN  CARDIAC  DISEASE,  Etc. 

Mechanical  H3rpotension. — When  the  total  volume  of  blood  is 
diminished  from  whatever  cause  (hemorrhage,  diarrhea,  sweating, 
polyuria)  a  fall  of  blood-pressure  may  result.  For  a  time,  of  course, 
this  may  be  counter-balanced  by  arterial  constriction.  Such  a  hypo- 
tension is  seen  typically  in  postpartum  hemorrhages.  Whether 
the  hypotension  seen  in  severe  anemias,  often  with  a  diminished 
viscosity,  has  a  similar  genesis  cannot  be  positively  asserted. 

Factors  which  hinder  the  flow  of  blood  to  or  from  the  right  heart 
(a  fall  of  venous  pressure,  adhesive  or  effusive  pericarditis,  obstruc- 
tion in  the  pulmonary  circuit,  portal  or  caval  obstruction,  etc.) 
produce  arterial  hypotension.  The  removal  of  serous  efl'usions  from 
the  peritoneum  or  pleura  tends  to  produce  a  similar  effect,  as  do 
also  cardiac  and  valvular  lesions  in  the  stage  of  broken  compen- 
sation. 

Functional  Hypotension. — This  form  of  hypotension  occurs  when 
vascular  tone,  especially  in  the  splanchnic  vessels,  is  below  the 
normal  or  when  a  local  vasodilatation  is  insufficiently  compensated 
for  by  local  constriction  elsewhere.  It  is  seen  chiefly  in  fevers 
(toxemia),  in  constitutional  low  arterial  tension,  and  in  medical  or 
surgical  shock. 

Terminal  Hypotension. — Terminal  hypotension  may  result  either 
from  mechanical  or  functional  causes.  By  this  term  we  mean  the 
ultimate  fall  of  pressure  which  occure  as  a  result  of  cardiovascular 
failure.  It  is  seen  in  the  agonal  and  preagonal  periods.  It  is  com- 
mon as  the  terminal  stage  of  hypertension,  in  which  the  pressure 
may  be  only  relatively,  not  actually,  below  the  normal.  Occasion- 
ally life  may  be  maintained  for  several  hours  or  even  days  with  a 
maximum  pressure  of  60  mm.  Hg.;  indeed,  figures  as  low  as  45  mm. 
(associated  with  unconsciousness  and  a  subnormal  temperature) 
have  been  reported  by  Neu. 

Diseases  of  the  Heart. — Despite  the  great  abnormalities  of  the 
circulation,  which  are  manifest  during  the  course  of  valvular  and 
myocardial  disease,  pressure  observations  often  show  relatively 
insignificant  changes.  Increased  blood-pressure  is  essentially  a  vas- 
cular and  myocardial,  not  a  valvular  phenomenon.    Excluding  the 


DISEASES  OF  THE  HEART  241 

conspicuous  findings  of  aortic  insufficiency  and  cardiorenal  hyper- 
tension, sphygmomanometric  readings  often  are  of  discouragingly 
little  clinical  value,  although  a  normal  systolic,  associated  with  a 
high  diastolic,  pressure  is  very  suggestive  of  myocardial  disease. 
This  is  due  to  the  fact  that  although  the  general  systemic  pressure 
may  be  normal,  the  rapidity  of  blood  flow,  the  mass  movement  of 
the  blood,  and  especially  the  normal  pressure  relations  between  the 
arteries,  arterioles,  capillaries  and  veins  have  been  either  locally 
or  generally  disturbed.  Regarding  these  conditions  ordinary 
sphygmomanometric  observations  teach  us  but  little  by  inference 
and  nothing  directly. 

In  valvular  disease  one  frequently  finds  diminished  pressure, 
100  to  110  mm.,  but  such  a  hypotension  is  more  often  attributable 
to  coincident  conditions,  such  as  fever,  etc.,  than  to  a  direct  cardiac 
effect.  In  acute  rheumatic  endocarditis  the  pressure  is  not  different 
from  that  in  old  valvular  lesions.  Rarely  blood-pressure  and  tem- 
perature rise  and  fall  together.  Only  exceptionally  does  the  pressure 
in  afebrile  cases  fall  below  90.  Not  infrequently  pressure  values 
remain  the  same  in  broken  compensation  and  during  subsequent 
improvement.  Digitalis  produces  practically  no  rise  of  pressure  in 
valvular  cases.  In  cardiac  decompensation  it  tends  to  increase  the 
pulse-pressure  rather  by  lowering  the  diastolic,  than  by  elevating 
the  systolic,  pressure. 

We  may  have  a  stasis  of  blood  due  to  increased  resistance  in  the 
peripheral  arteries  without  elevation  of  either  the  systolic  or  the 
diastolic  pressure.  The  condition  which  Sahli  has  described  as  high- 
pressure  stasis  ("  hochdruckstauung")  occurs  when  the  arterioles 
are  tonically  contracted  or  sclerotic  so  that  outflow  is  prevented. 
Under  such  circumstances  even  an  insufficient  heart  may,  by  forc- 
ing gradually  more  blood  into  the  arterial  reservoir,  increase  the 
pressure.  This  is  further  abetted  by  the  accumulation  of  CO2  in 
the  blood,  which,  by  stimulating  the  vasomotor  centre,  leads  to 
still  further  arterial  contraction. 

In  these  cases  a  plethoric,  cyanotic  face  is  often  associated  with 
edema  and  other  evidences  of  cardiac  failure,  together  with  high 
arterial  tension,  which  falls  when  circulatory  improvement  occurs. 
This  is  attributable  to  improved  renal  elimination,  to  a  diminu- 
tion of  carbon  dioxide  tension  in  the  blood  and  to  lessened  hydremic 
plethora  (see  p.  276).  A  fall  of  pressure  is  of  serious  import  chiefly 
when  associated  with  a  rise  of  venous  pressure,  the  latter  being 
manifested  by  hepatic  and  pulmonary  congestion.  Vascular  reflexes 
are  sometimes  abolished  in  advanced  cardiac  disease. 
16 


242  BLOOD-PRESSURE  IN  CARDIAC  DISEASE 

Aortic  Insufficiency. — ^Experimental  Data. — The  establishment  of 
experimental  aortic  insufficiency  in  animals,  insofar  as  concerns 
the  mean  arterial  pressure,  has  shown  divergent  results.  Some 
investigators  have  reported  a  fall  of  the  mean  pressure;  others  but 
little  change.  The  results  seen!  to  depend,  at  least  in  part,  upon 
the  cardiac  strength  of  the  animal  in  question — dogs  bearing  the 
lesion  better  than  rabbits.  As  a  rule  there  is  some  fall  of  the  mean 
pressure,  the  amount  of  which  tends  to  vary  with  the  duration  and 
severity  of  the  lesion. 

The  arterial  pressure  is  perhaps  maintained  in  suddenly  estab-- 
lished  aortic  lesions  by  the  vasomotor  and  cardiac  reflexes  which 
are  engendered  by  stimulation  of  the  endocardium,  but  the  chief 
factor  of  compensation  lies  in  the  heart  muscle  itself.  The  mean 
pressure  is  maintained  chiefly  as  the  result  of  enlargement  and 
hypertrophy  of  the  left  ventricle,  which  lead  to  an  increased  systolic 
output.^ 

The  experiments  of  Stewart^  indicate  that  much  less  blood  actu- 
ally regurgitates  into  the  heart  during  diastole  than  is  generally 
supposed.  This  is  owing  to  the  increased  tonicity  which  the  left 
ventricle  assumes.  The  great  difference  between  the  systolic  and 
the  diastolic  pressure  which  occurs  has  been  attributed  to  a  reflex 
lowering  of  the  minimum  pressure.  The  main  fall  of  pressure  is 
systolic  in  time,  and  is  due  to  increased  capillary  flow.  This  is  borne 
out  by  the  fact  that  even  in  case  of  good  compensation  the  diastolic 
pressure  may  range  between  40  and  60  mm.  Hg.,  while  the  systolic 
pressure  is  about  ISO  mm.  The  tremendous  pressure  fluctuations 
to  which  the  arteries  are  subjected  is  an  important  factor  in  the 
arteriosclerotic  changes  which  the  vessels  undergo  in  these  cases. 

Wiggers's'*  studies  with  optical  manometers,  however,  indicate 
that  the  rapid  systolic  fall  of  pressure  is  not  due  to  vasodilatation, 
since  (1)  the  change  occurs  too  rapidly  (within  a  single  beat),  (2) 
it  occurs  even  when  the  vessels  have  been  previoush"  dilated  by 
means  of  nitroglycerin,  and  (3)  the  condition  is  enhanced  rather 
than  abated  by  epinephrin. 

He  attributes  the  dynamic  changes  of  aortic  insufficiency  to  the 
fact  that  the  initial  intraventricular  tension  is  increased  "owing  to 
a  regurgitation  of  pressure  during  diastole;  this  in  turn  causes  a 
more  vigorous  ejection  of  a  larger  blood  volume  in  the  early  portion 
of  the  next  systole.     This  may  be  accompanied  by  an  actual 

'  Krehl,  L.:    Pathologische  Physiologie,  1910,  p.  18. 

^  Experimental  and  Clinical  Investigations  of  the  Pulse  and  Blood-pressure  changes 
in  Aortic  Insufficiency,  Arch.  Int.  Med.,  1908,  i,  102. 

'  The  Dynamics  of  Aortic  Insufficiency,  Arch.  Int.  Med.,  1915,  xvi,  132. 


AORTIC  INSUFFICIENCY  .  243 

decreased  ejection  during  the  latter  portion  of  systole,  thus  at 
once  accounting  for  the  facts  (a)  that  the  systolic  decline  becomes 
steeper  and  (6)  that  the  total  systolic  output  may  not  increase 
appreciably  beyond  the  normal." 

Clinical  Data. — The  enormous  pulse-pressure  which  in  exceptional 
cases  may  amount  to  120  mm.  Hg.  and  which  is  frequently  seen  in 
aortic  insufficiency  with  good  compensation  is  often  sufficient  to 
alone  establish  a  diagnosis.  This  finding  is  analogous  to  the  other 
pulsatory  phenomena  which  are  so  characteristic  of  this  lesion. 

Landolfi,  Rocb,  and  others  have  reported  circulatory  hippiis  as  a 
sign.  It  is  generally  manifest  when  the  pulse  is  slow  and  the  systole 
powerful  (digitalis).  Myosis  corresponds  with  systole  or  increased 
pressure. 

A  high  systolic  (180  to  200  mm.)  associated  with  a  low  diastolic 
(60  to  30' mm.)  pressure  is  strong  presumptive  evidence  in  favor 
of  aortic  regurgitation.  In  estimating  the  diastolic  pressure  by  the 
auscultatory  method  the  fourth  phase  must  be  chosen  as  the  cri- 
terion, since  the  fifth  phase  often  persists  down  to  0  mm.  This 
phenomenon  is  suggestive  but  not  pathognomonic  of  aortic  insuffi- 
ciency. A  fall  of  pressure  often  indicates  a  failing  ventricle.  We 
should  not  speak  of  hypertension  in  cases  of  aortic  insufficiency 
unless  the  systolic  pressure  exceeds  200  mm. 

The  intensity  of  the  diastolic  aortic  murmur  in  some  cases 
increases  with  a  rise  of  systolic  pressure.  A  fall  of  pressure  may 
cause  a  feeble  murmur  to  become  inaudible.  The  arterial  sound, 
heard  in  some  cases  in  the  femoral  artery  without  aortic  leakage 
depends  to  a  considerable  extent  upon  the  pulse-pressure,  but 
especially  upon  the  existence  of  an  abnormally  low  diastolic  pressure 
(Dehio).*^ 

Differences  in  the  Blood-pressure  in  the  Arm  and  Leg. — Under 
norvml  conditions  the  systolic  pressures  in  the  arm  and  leg  of  an 
individual  lying  quietly  in  a  horizontal  position  are  equal.  When 
the  erect  or  an  inverted  posture  is  assumed  the  pressures  in  the 
arm  and  leg  "differ  by  the  hydrostatic  pressure  of  the  column  of 
blood  which  separates  the  points  of  the  measurements.  In  these 
postures  the  pressure  in  the  arteries  of  the  leg  varies  greatly,  while 
in  the  arm  the  pressure  is  kept  about  the  same  by  the  mechanism 
which  compensates  for  the  influence  of  gravity."  In  aortic  insuffi- 
ciency a  great  difference  between  the  arm  and  leg  pressures  in  the 
recumbent  posture  has  been  found  (150  mm.  Hg.  higher  in  the  leg) 
which  is  of  diagnostic  significance.  It  is  most  marked  in  uncompli- 
cated and  compensated  cases  and  diminishes  as  soon  as  mitral 


244  BLOOD-PRESSURE  IN  CARDIAC  DISEASE 

insufficiency  and  dilatation  of  the  right  heart  occur.  Both  fever 
and  the  appHcation  of  hot  water  lessen  the  difference  by  relaxing 
arterial  tone  in  the  lower  extremities/  in  which  the  arteries  are 
assumed  to  be  in  a  contracted  state  in  an  effort  to  prevent  cerebral 
anemia.2  Another  explanatiori  of  the  higher  leg  pressure  is  offered 
by  Hill  and  Wells^  who  believe  that  it  is  due  to  a  better  conduction 
of  the  pulse  wave  in  contracted  and  more  rigid  arteries.  Hill^ 
has  recently  stated  that  in  addition  to  the  just  mentioned  factors 
the  resonating  effect  (periodic  vibration)  of  the  abdominal  cavity 
also  plays  a  part.  According  to  the  latter  conception  "  Resonation 
of  the  tissues  must  be  held  to  play  an  important  part  in  the  trans- 
mission of  the  pulse,  and  thereby  to  save  the  work  of  the  heart. 
The  work  of  the  heart  we  know  is  largely  conserved  by  the  elastic 
recoil  of  the  arteries.  But  this  elastic  recoil  of  the  arteries  is  aided 
by  the  resonance  of  the  tissues.  Every  artery  is  in  intimate  relation- 
ship with  its  immediate  neighbor.  The  pulse  of  one  individual 
artery  is  aided  by  the  pulses  of  the  other  arteries.  The  vigor  of 
the  circulation  depends  on  the  tone  of  the  tissues,  on  the  tautness 
of  skin  and  muscle,  and  particularly  of  the  abdominal  wall.  The 
hardened  body  of  the  trained  athlete  swings  in  full  resonance  with 
the  pulse  of  his  heart;  the  soft,  flabby,  ill-conditioned  body  of  the 
sedentary  worker  offers  a  poor  slack  drum  for  his  heart  to  thump." 

Cases  Illustrating  the  Differences  in  Arm  and  Leg  Pressures  in  Aortic 
Insufficiency  as  Compared  with  Other  Cardiac  Lesions. 

Blood-pressure 
Brachial.  Ext.  malleolar. 

No.  Diagnosis.  Systolic.      Diastolic.  Systolic.     Diastolic. 

1  Arteriosclerosis,  chronic  nephritis,  car- 

diac hypertrophy  and  dilatation, em- 
physema of  lungs,  portal  congestion       171  106  167  107 

2  Mitral  and  tricuspid  insufficiency,  car- 

diac dilatation,  passive  congestion  of 

lungs,  liver,  kidneys,  portal  system       113  75  112  80 

3  Aortic  obstruction  and  insufficiency, 

arteriosclerosis,  mitral  insufficiency 

cardiac  hypertrophy,  etc.      .      .      .        151  69  191  122 

4  Aortic  obstruction   and  insufficiency 

mitral  insufficiency,  arteriosclerosis, 
I         chronic  nephritis,  etc 173  71  190  95 

5  Cardiac  hypertrophy  and  dilatation, 

aortic  insufficiency 222  127  300  190 

'  Rolleston,  H.  D. :  On  the  Systolic  Blood-pressure  in  the  Arm  and  Leg  in  Aortic 
Incompetence,  Heart,  1912,  iv,  83. 

^  Hill,  Flack,  and  Holzman:  The  Measurement  of  Systolic  Blood-pressure  in  Man, 
Heart,  1909,  i,  73.  Hill  and  Rowlands:  Systolic  Blood-pressure,  Heart,  1912,  iii, 
219. 

»  Wells,  Russell,  and  Hill:  Roy.  Soc.  Proc,  1913,  B.  bcxxvi,  180.  HiU  and  Flack: 
ibid.,  p.  365. 

^HUl,  McQueen,  and  Ingram:  The  Resonance  of  the  Tissues  as  a  Factor  in  the 
Transmission  of  the  Pulse  and  in  Blood-pressure,  Proc.  Roy.  Soc,  London,  1914, 
Ixxxvii,  255. 


AORTIC  ANEURYSM  245 

In  Cases  1  and  2  there  was  no  aortic  leakage.  The  arm  and  leg 
pressures  in  the  recumbent  position  were  approximately  equal.  In 
Cases  3  and  4  (definite  aortic  insufficiency)  there  were  marked 
differences  in  pressure.  In  Case  5  aortic  regurgitation  was  doubt- 
ful, but  the  large  pulse- pressure,  as  well  as  the  arm  and  leg  differ- 
ence, were  strong  evidence  in  favor  of  the  existence  of  the  lesion. 

The  difference  in  the  arm  and  leg  pressures  just  referred  to,  while 
suggestive  and  corroborative,  are  not  pathognomonic  of  aortic 
insufficiency.  They,  as  well  as  a  large  pulse-pressure,  are  met  with 
in  arteriosclerosis.^ 

Trauhes  Sign — a  double  to7ie  heard  over  the  femoral  vessels — 
occurs  chiefly  in  aortic  insufficiency,  as  does  also  Duroziez's  sign — a 
double  murmur  heard  as  the  result  of  stethoscopic  compression  of 
the  femoral  artery.  Both  of  these  phenomena  are  most  marked 
when  the  pulse-pressure  is  large.  The  former  is  caused  by  sudden 
distention  of  the  artery  by  the  large  systolic  output  and  by  the 
sudden  distention  of  the  femoral  vein  due  to  tricuspid  insufficiency.- 

Huchard  found  that  in  aortic  insufficiency^  of  rheumatic  origin 
the  systolic  pressure  was  increased  only  moderately;  the  diastolic 
pressure  was  subnormal;  while  in  cases  of  arteriosclerotic  origin  both 
phases  were  markedly  elevated.  These  findings  he  attributed  to 
the  greater  valvular  damage  in  Group  1  and  the  coincident  presence 
of  renal  lesions  in  Group  2.^ 

Aortic  Obstruction. — In  pure  aortic  obstruction  the  systolic,  the 
diastolic  and  the  pulse-pressures  are  generally  slightly  elevated, 
due  in  part  to  left  ventricular  hypertrophy  and  in  part  to  general 
arteriosclerotic  changes.  The  pulse-pressure  is  small,  and  the  pulse 
feels  hard  and  small,  being  gradual  both  in  onset  and  in  disap- 
pearance. 

Aortic  Aneurysm. — Many  cases  of  aortic  aneurysm  have  a  normal 
arterial  pressure.  According  to  Williamson,*  blood-pressure  tenets 
to  be  higher  in  cases  of  simple  aortic  dilatation  than  in  cases  in 
which  a  distinct  aneurysm  is  present.  A  pressure  difference  (5  to 
20  mm.)  in  the  two  arms  is  very  commonly  found,  and  occurs  in 
about  the  same  proportion  of  cases  whether  the  innominate  artery 
is  actually  involved  or  not.    Differences  amounting  to  30  mm.  or 

•  Taussig,  A.  E. :  Some  Blood-pressure  Phenomena  in  Exophthalmic  Goitre,  Tr. 
Assn.  Am.  Phys.,  1916,  xxxi,  121. 

'  Schultz,  W. :  Ueber  d.  Doppeltonbildung  a.  d.  Cruralgefaessen,  Deutsch.  med. 
Wchnschr.,  1905,  xxxi,  2,  1381.  Tite,  T.:  Clinical  Significance  of  Some  Peripheral 
Signs  of  Aortic  InsuflBciency,  Illinois  Med.  Jour.,  September,  1911. 

'  Huchard,  H.,  and  Amblard :  La  tension  art^rielle  dans  les  insuffisances  aortiques, 
Jour,  de  Practiciens,  May  29,  1909. 

« Lancet,  November  30,  1907. 


246  BLOOD-PRESSURE  IN  CARDIAC  DISEASE 

more  occur  in  about  one-third  of  the  cases  and  indicate  aneurysm 
rather  than  simple  dilatation  or  mediastinal  tumor,  which  latter 
causes  inequality  of  tension  somewhat  less  frequently  than  does 
aneurysm.  Small  inequalities  of  pressure  are  of  little  practical 
diagnostic  value.  Unilateral  differences  of  10  mm.  in  the  two  arms 
without  any  constancy  as  to  the  side  occurred  in  20  per  cent,  of 
36  cases  studied  by  Phipps.^  The  administration  of  potassium 
iodide  or  the  injection  of  sterilized  gelatin,  which  often  relieves 
pain,  has  no  effect  on  arterial  tension.^ 

Unilateral  pressure  differences  may  also  be  encountered  in  arterio- 
sclerosis, in  hemiplegia,  and  in  cases  of  cervical  rih.  In  the  last- 
named  condition  lowering  of  the  arm  sometimes  produces  a  demon- 
strable decrease  in  the  pulse-pressure. 

Increased  blood-pressure,  especially  that  which  is  due  to  sudden 
muscular  strain  is,  next  to  disease  of  the  elastic  fibers  of  the  arterial 
media,  the  most  important  factor  in  the  production  of  an  aneurysm. 

Phlebotomy  which  is  often  a  very  useful  method  of  therapeusis 
in  aneurysm,  lowers  blood-pressure,  and  if  the  blood  withdrawn  has 
been  considerable  in  quantity — one  pint  or  more — the  patients  are 
often  symptomatically  benefited  for  weeks  or  months. 

Subclavian  Aneurysm. — Dilatation  or  aneurysm  of  the  subclavian 
artery  has  been  reported  in  a  number  of  instances  as  a  result  of 
pressure  upon  the  artery  by  cervical  ribs.  The  vascular  abnormality 
occurs  distal  to  the  site  of  pressure.  The  mechanism  by  which  dila- 
tation occurs  has  been  investigated  by  Ried^  who  found  that  if  the 
canine  abdominal  aorta  is  partially  occluded  by  a  metallic  band, 
the  systolic  pressure  in  this  vessel  falls,  while  the  diastolic  pressure 
rises.  Based  upon  the  foregoing  experiments  Halstead  believes  that 
the  subclavian  dilatation  is  not  a  result  of  vasomotor  paralysis, 
trauma  or  sudden  variations  in  blood-pressure,  but  is  due  to  the 
abnormal  whirlpool-like  play  of  the  blood  in  the  relatively  dead 
pocket  just  below  the  site  of  the  constriction  and  the  lower  pulse- 
pressure. 

Mitral  Lesions. — ^In  compensated  mitral  insufficiency  arterial 
pressure  is  practically  normal.  The  reestablishment  of  functional 
efficiency  after  an  attack  of  broken  compensation  is,  as  was  first 
pointed  out  by  Sahli,  not  rarely  associated  with  a  diminution  of 
blood-pressure.    In  mitral  lesions  this  rule  applies  to  both  maximum 

'  Boston  Med.  and  Surg.  Jour.,  1915,  clxxiii,  476. 

'  Mackinnon,  M. :  Arterial  Pressure  in  Thoracic  Aneurysms,  British  Med.  Jour., 
October  4,  1913. 

'  Partial  Occlusion  of  the  Aorta  with  the  Metallic  Band.  Observations  on  Blood- 
pressures  and  Changes  in  the  Arterial  Walls,  Jour.  Exper.  Med.,  1916,  xxiv,  287. 


MITRAL  LESIONS 


247 


and  minimum  pressures.  The  same  phenomena  occur  to  an  even 
greater  extent  in  the  broken  compensation  which  occurs  in  pul- 
monary emphysema.  In  aortic  and  arteriosclerotic  lesions  the  fall 
of  pressure  is  much  less  marked.  These  apparently  paradoxical 
phenomena  are  due  to  the  fact  that  during  the  period  of  insuffi- 
ciency the  resistance  to  arterial  outflow  is  increased  as  the  result 
of  (1)  CO2  accumulation  in  the  blood  which  produces  peripheral 
vasoconstriction,  and  (2)  owing  to  increased  venous  pressure.  The 
physics  of  this  phenomena  are  illustrated  in  the  following  diagram : 


H 


M 


1 


D 


Fig.  91. — Diagram  illustrating  the  rise  of  arterial  pressure  which  results  from 
increased  peripheral  resistance.     (After  Lang  and  Manswetowa.) 


The  reservoir  {H)  is  filled  with  water  which  escapes  through  P 
(the  capillaries)  by  means  of  A  (arteries).  If  the  stopcock  be  wide 
open,  water  will  rise  in  the  standpipe  M  (pressure)  to  the  point  n. 
If  the  stopcock  be  partially  closed  (increased  peripheral  resistance) 
it  will  rise  to  m,  and  even  with  a  diminished  head  in  H  (lessened 
cardiac  power)  it  will  still  rise  to  0. 

A  rise  in  the  'pulse-pressure  during  symptomatic  improvement  is 
less  constant,  and  when  present  it  is  more  frequent  in  mitral  lesions 
and  in  emphysema.  This  has  been  explained  as  due  to  the  fact 
that  under  these  circumstances  the  loss  of  compensation  is  the 
result  of  right  heart  weakness,  the  left  heart  being  unaffected  and 
being  opposed  by  a  greater  peripheral  tonus.  With  a  constant 
blood  flow,  aortic  pressure  and  pulse-pressure  increase  coincidently.^ 
The  reestablishment  of  compensation  must  be  associated  with 
better  cardiac  filling  and  more  forcible  contraction.  As  soon  as  an 
improved  circulation  occurs,  oxygenation  of  the  blood  is  increased 
and  peripheral  spasm  relaxes.^    Several  observers  have  constantly 

>  Fiirst  and  Soetbeer:  Untersuchungen  u.  d.  Beziehungen  zw.  Fiillung  u.  Druck 
m.  d.  Aorta,  Deutsch.  Arch.  f.  klin.  Med.,  1907,  xc,  190.  Strassburger:  Ueber  d. 
Einfluss  f.  .\ortenelastizitat  a.  d.  Verhaltniss  zw.  Pulsdruck  u.  Schlagvolumen  d. 
Herzens,  ibid.,  1907,  xci,  378. 

'  Lang,  G.,  and  Manswetowa,  S.:  Zur  Frage  d.  Veriinderung  des  arteriellen  Blut- 
druckes  bei  Herzkrankheiten  wahrend  d.  Kompensationsstorung,  Deutsch.  .\rch.  f. 
klin.  Med.,  1908,  xciv,  455.  (See  Bibliography  and  numerous  statements  in  the 
foregoing  discussion.) 


248  BLOOD-PRESSURE  IN  CARDIAC  DISEASE 

found  that  a  temporary  increase  of  pulse-pressure  occurs  at  the 
beginning  of  compensatory  reestablishment. 

In  compensated  mitral  obstruction  pressure  is,  owing  to  peripheral 
vasoconstriction,  more  often  above  than  below  the  normal.  The 
pulse-pressure  is  small.  Hypotension  may  therefore  be  of  some 
value  in  diagnosticating  between  hemoptysis  due  to  tuberculosis 
and  that  due  to  mitral  obstruction. 

Lagrange^  found  the  arteriocajrillary  pressure  (as  indicated  by 
the  sphygmomanometer  of  Bouloumie)  in  mitral  stenosis  higher 
than  normal,  the  arterial  pressure  about  normal.  In  cases  asso- 
ciated with  arteriosclerosis,  pressure  was  distinctly  elevated  (180 
mm.),  and  in  such  cases  a  sudden  fall  was  prognostically  grave. 

The  blood  flow  in  two  cases  of  mitral  obstruction  studied  by 
Means  and  Newburgh^  showed  a  very  small  (1.3,  2.2  L  per  minute, 
normal  4  to  4^)  volume,  together  with  a  high  coefficient  of  utiliza- 
tion of  the  oxygen-carrying  capacity  and  an  increase  in  hemoglobin. 
This  combination  of  factors  would  seem  to  act  conservatively  in 
these  patients,  since  relatively  more  oxygen  is  carried  to  the  tissues 
by  a  given  quantity  of  blood  flow. 

Edema  and  Blood-pressure. — It  has  been  suggested  that  edema 
increases  blood-pressure  by  mechanically  compressing  the  peripheral 
arteries,  and  that  this  plays  a  part  in  the  increased  pressure  which 
is  seen  in  broken  compensation.  If  it  ever  plays  any  such  part  it 
must  be  a  very  insignificant  one,  since  ordinarily  edema  and  vascular 
tension  bear  no  constant  relation  to  each  other.  Pressure  may 
either  rise  or  fall  while  dropsy  increases  or  diminishes.  The  occur- 
rence of  edema  in  cardiac  no  less  than  in  renal  disease  is  not,  as 
formerly  supposed,  merely  a  question  of  hemodynamics  but  is 
closely  related  to  certain  metabolic  abnormalities,  notably  the 
retention  of  sodium  chloride  in  the  body. 

Experimentally  puke-pressure  bears  a  definite  relation  to  edema 
and  infarction.  It  has  been  shown  that  edema,  which  occurs  read- 
ily in  perfused  organs,  may  be  largely  prevented  if  an  intermit- 
tent— pulsating — pressure  be  employed.^  Erythrocytic  diapedesis 
occurs  at  the  point  at  which  pulsation  of  the  arteries  can  no  longer 
be  seen.'' 

In  uncomplicated  valvular  disease  in  which  an  increased  pressure 

'  Essai  de  Sphygmotonometrie  clinique  appliqu6e  au  diagnostic  du  retr6cissement 
mitral,  Arch.  gen.  de  M6d.,  1908,  excix,  293. 

2  Tr.  Assn.  Am.  Phys.,  1915,  xxx,  51. 

'  Hamel:     Die  Bedeutung  des  Pulses  f.  d.  Blutstrom,  Ztschr.  f.  Biol.,  1889,  xxv,  447. 

*  Mall  and  Welch:  Thrombosis  and  Embolism,  Albutt's  System  of  Medicine, 
1899,  p.  254. 


EXTRASYSTOLIC  ARRHYTHMIA  249 

exists  no  effort  should  be  made  to  lower  tension  by  means  of  vaso- 
dilator remedies.  Vasoconstriction  is  in  these  cases  an  effort  to 
correct  myocardial  insufficiency  by  inciting  the  ventricles  to  restore 
the  proper  output  (Starling).  An  increased  pressure  during  com- 
pensation may  be  necessary  to  insure  the  requisite  speed  of  capillary 
flow.i     (See  p.  296.) 

Myocardial  Disease. — Much  of  what  I  have  stated  regarding 
arteriosclerosis  and  arterial  hypertension  applies  to  myocardial  dis- 
ease, because  the  latter  generally  is  very  frequently  the  terminal 
stage  of  the  former.  Since  it  is  impossible  to  differentiate  clinically 
between  different  forms  of  myocardial  degeneration,  they  may  be 
considered  as  a  group. 

As  in  valvular  lesions,  blood-pressure  in  chronic  myocardial  dis- 
ease is  variable,  although  with  the  exception  of  the  terminal  stages, 
an  increase  will  usually  be  found.  The  pulse-pressure  is  often 
small.  Such  a  finding  is  common  even  when  functional  capacity 
is  far  from  good.  In  these  cases  exertion  produces  oppression, 
dyspnea,  etc.,  and  a  fall  of  pressure.  Stewart  found  a  slow  blood 
flow  as  low  as  0.2  gm.  per  100  c.c.  per  minute  as  compared  with 
a  normal  of  3  to  5  to  14  gm.  Not  infrequently  myocardial  cases 
show  a  normal  systolic  but  a  high  diastolic  pressure.  Rosenfeld^ 
believes  that  a  very  low  blood-pressure  associated  with  mild 
anginal  attacks,  dilatation  of  the  left  ventricle  and  aorta,  and 
auricular  fibrillation,  especially  if  associated  with  a  positive  Wasser- 
mann  reaction,  points  strongly  to  syphilitic  myocarditis.  Sal- 
varsan  must  be  administered  with  caution  in  these  cases  owing 
to  its  tendency  to  lower  blood-pressure  and  bring  on  tachycardia. 
The  absence  of  hypertension  and  cardiac  hypertrophy  in  syphilitic 
arterial  disease  was  pointed  out  by  Cautley.^ 

Extrasystolic  Arrhythmia. — ^The  genesis  of  this  form  of  cardiac 
irregularity  may  be  closely  associated  with  arterial  tension.  Both 
experimentally  and  clinically  it  is  often  induced  by  increasing 
arterial  pressure  and  abated  when  tension  is  diminished.  When 
due  to  such  a  cause  it  may  be  interpreted  as  an  indication  that  the 
heart  is  beginning  to  stagger  under  its  burden.  The  extrasystoles 
themselves  are  less  forcible  than  the  regular  contractions,  and  the 
ventricle  is  less  well  filled.  Hence  their  systolic  pressure  level  is 
lower  than  that  of  the  regular  contraction.    The  postextrasystolic 


*  Korke,  V.  T. :     Systolic  Blood-pressure  in  Diseases  of  the  Heart,  Lancet,  Decem- 
ber 2,  1911,  p.  1547. 

*  Ueber  Syphilitische  Myocarditis,  Deutsch.  med.  Wchnschr.,  1914,  xl,  1044. 
»  Lancet,  April  6,  1901. 


250  BLOOD-PRESSURE  IM  CARDIAC  DISEASE 

pressure  is  often  higher — prolonged  diastole.  The  existence  of 
hypotension  in  association  with  extrasystoles,  other  things  being 
equal,  points  to  a  purely  functional  origin  of  the  arrhythmia. 

Tachycardia. — Low  blood-pressure  is  generally  associated  with 
tachycardia,  especially  in  fevers.  When  heart  action  is  very  rapid, 
diastole  is  too  short  to  allow  adequate  venous  inflow,  and  hence 
output  must  fall.  In  such  cases  the  hypotension  may  in  part  be 
responsible  for  the  rapid  pulse,  although  both  symptoms  are  in  the 
main  the  result  of  toxemia.  In  paroxysmal  tachycardia  there  is, 
during  the  paroxysm,  often  a  fall  of  the  arterial  and  a  rise  of  the 
venous  pressure  due  to  insufficient  diastolic  filling  of  the  ventricles. 

Bradycardia. — Bradycardia  is  often  accompanied  by  relatively 
slight  blood-pressure  changes.  With  a  very  slow  pulse,  however, 
the  diastolic  pressure  is  generally  considerably  below  the  normal. 
Gibson  has  reported  heart  block  associated  with  a  pressure  of 
^8^  mm.  In  the  cases  of  Adams-Stokes  disease  coming  under  my 
personal  observation  the  following  readings  were  made: 

„o  235    „„  150         210  117  155      „  90    „„  115    ^,       systolic 

36  -— ,  30  — -,  24  --,  48  --,  36  --,  30  —,  30  — -,  Pulse 


140'         100'  85 '  85  '  65  '         65'  85 '  diastolic 

Bradycardia  is  sometimes  due  to  increased  arterial  tension.  The 
latter  condition  produces  central  stimulation  of  the  vagus,  and  this 
in  turn  a  slowing  of  the  pulse.  When  the  hypertension  is  gradual 
in  onset,  an  increased  pulse  rate  is  the  rule,  but  when  it  is  sudden, 
as  occurs  experimentally  and  in  cases  of  acute  nephritis,  brady- 
cardia is  more  apt  to  result  (Krehl). 

Pulsus  Altemans. — A  marked  increase  in  pressure  is  the  rule;  in 
fact,  this  form  of  arrhythmia,  which  is  generally  attributed  to  fail- 
ure of  ventricular  contractility,  may  disappear  with  a  fall,  and 
recur  with  a  rise,  of  arterial  pressure.  Herrick^  finds  the  sphygmo- 
manometer useful  not  only  in  detecting  latent  cases  of  pulsus 
alternans,  but  also  in  increasing  the  tactile  perception  of  the  alter- 
nation. The  cuff  is  inflated  to  the  point  at  which  the  pulse  rate 
becomes  halved.  If  the  cuff  pressure  is  allowed  to  fall  somewhat 
lower  all  the  beats  will  come  through,  but  the  alternation  in  their 
size  becomes  more  noticeable  than  when  the  arterial  lumen  is 
uncom  promised. 

Auricular  Fibrillation. — In  auricular  fibrillation  successive  pulse 
waves  are  so  extremely  variable  in  both  size  and  tension  that  it 
is  not  possible  to  draw  any  accurate  conclusions  from  ordinary 

1  Jour.  Am.  Med.  Assn.,  February  27,  1915. 


AURICULAR  FIBRILLATION 


251 


blood-pressure  readings.  The  largest  pulse  waves  are  often  40  to 
50  mm.  higher  than  the  smallest.  An  approximate  average  pressure 
may  be  obtained,  as  suggested  by  Janeway,  by  noting  the  pressure 
of  the  largest  and  the  smallest  pulse  waves  separately,  a  method 
which  emphasizes  the  number  of  waves  which  fail  to  come  through 
at  a  certain  pressure.  Silberberg^  employs  a  Mackenzie  polygraph, 
upon  which  he  records  the  pulsations  of  both  radial  arteries,  one  of 
them  under  increasing  degrees  of  cuff  pressure,  thus  obtaining  a 
graphic  record  of  the  relative  pressure  of  different  systoles  (Figs. 
92,  93  and  94). 


Fig.  92 


90 


too 


Fig.  93 


'  lao* 


130 


MO 


Fig.  94 
Figs.  92,  93  and '94. — Three  strips  of  tracing  (right  and  left  radial)  taken  from 
the  same  patient.     Fig.  92,  before  brachial  compression;  all  the  beats  come  through. 
Fig.  93,  the  smallest  beats  (xx)  disappear  at  a  pressure  between  90  and  100  mm.  Hg. 
Fig.  94,  the  largest  beats  fail  to  record  at  a  pressure  of  140  mm.  Hg. 

A  more  satisfactory  method  of  estimating  blood-pressure  in 
auricular  fibrillation  has  been  suggested,  based  upon  what  is  knowTi 
as  the  relative  pulse  deficit.^ 

The  pressure  in  the  cuff  which  has  been  raised  above  the  highest 
systolic  pressure  is  allowed  to  fall  10  mm.  at  a  time  and  interrupt- 


•  British  Med.  Jour.,  April  6,  1912. 

*  James,  W.  B.,  and  Hart,  T.  S. :     Auricular  Fibrillation;  Clinical  Observations  on 
Pulse  Deficit,  Digitalis,  and  Blood-pressure,  Am.  Jour.  Med.  Sc,  1914,  cxlvii,  G3. 


252 


BLOOD-PRESSURE  IN  CARDIAC  DISEASE 


ediy  checked.  A  count  is  now  made  of  the  number  of  pulse  waves 
which  pass  the  cuff  at  a  given  pressure,  in  relation  to  the  number  of 
cardiac  contractions  as  counted  per  minute  over  the  precordium 


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Fig.  95. — The  shaded  area  represents  the  piilse  deficit;  the  upper  edge  is  the 
apex  rate;  the  lower  edge  is  the  radial  rate.  The  broken  line  indicates  the  range 
of  the  "average  systolic  blood-pressure."  Digitalis  figures  indicate  minims  of  the 
tincture  and  drams  of  the  infusion.  October  13,  admitted  to  hospital.  November 
3,  up  in  chair  half  an  hour;  November  9,  up  in  chair  two  hours.  December  4,  up  in 
chair  four  hours.  At  this  time  she  had  a  crop  of  external  hemorrhoids  which  caused 
much  distress.     (James  and  Hart.) 

by  an  assistant.  The  excess  of  the  latter  over  the  former  consti- 
tutes the  "deficit."  The  process  is  repeated  until  all  the  beats 
traverse  the  cuff — until  there  is  no  deficit. 


Brachial  pressure. 

Radial  count. 

Apex  count 

140  mm. 

0 

64 

130      " 

60 

64 

120      " 

58 

64 

no    " 

62 

64 

100      " 

62 

64 

In  this  case  there  is  no  actual  deficit,  because  below  100  mm. 
all  the  beats  reach  the  periphery.  But  there  is  a  relative  deficit 
which  occurs  as  soon  as  pressure  is  raised  above  100  mm. 
The  "average  systolic  pressure"  is  determined  as  follows: 
"  The  apex  and  radial  are  counted  for  one  minute,  then  a  blood- 
pressure  cuff  is  applied  to  the  arm,  and  the  pressure  raised  until 
the  radial  pulse  is  completely  obliterated ;  the  pressure  is  then  low- 
ered 10  mm.  and  held  at  this  point  for  one  minute  while  the  radial 


AURICULAR  ARRHYTHMIA  253 

puke  is  counted;  the  pressure  is  again  lowered  10  mm.  and  a  second 
radial  count  is  made;  this  count  is  repeated  at  intervals  to  10  mm. 
lowered  pressure  until  the  cuff  pressure  is  insufficient  to  cut  off 
any  of  the  radial  waves  (between  each  estimation  the  pressure  on 
the  arm  should  be  lowered  to  0).  From  the  figures  thus  obtained 
the  average  systolic  blood-pressure  is  calculated  by  multiplying 
the  number  of  radial  beats  by  the  pressures  under  which  they 
came  through,  adding  together  these  products  and  dividing  their 
sum  by  the  number  of  apex  beats  per  minute.  The  resulting  figure 
is  what  we  have  called  the  'average  systolic  blood-pressure.'  " 
The  following  observation  made  on  a  patient  will  indicate  the 
method  of  computation: 
B.  S.,  April  29,  1910.    Apex,  131;  radial,  101;  deficit,  30. 


Brachial 

pressure. 

Radial  count. 

100] 

mm. 

0 

90 

13                   13  X  90  =  1170 

80 

47  -  13  =  34  X  80  =  2720 

70 

75  -  47  =  28  X  70  =  1960 

60 

82  -  75  =    7  X  60  =    420 

50 

101  -  82  =  19  X  50  =    950 
Apex  =  131)7220 

Average  systolic  blood-pressure         55 

Kilgore^  has  suggested  the  following  method  which  is  more 
accurate  than  that  just  described. 

The  Fractional  Method.— This  method  differs  from  that  of  James 
and  Hart  in  the  fact  (1)  that  diastolic  readings  are  made  by  deter- 
mining the  fifth  auscultatory  phase,  and  (2)  by  a  different  interpre- 
tation of  the  systolic  readings. 

These  readings  are  made  at  5  instead  of  10  mm.  Hg.  intervals, 
and  are  tabulated  as  having  an  average  value  of  7.5  mm.  Thus  in 
a  given  case  with  88  pulse  beats  per  minute  and  a  pressure  ranging 
between  110  and  145  mm.  the  chart  and  figures  shown  on  page 
254  were  obtained. 

Lewis,^  who  experimentally  investigated  the  effect  of  auricular 
fibrillation  upon  the  circulation  as  a  whole,  found  that  blood- 
pressure,  while  it  might  rise  or  fall  or  remain  unchanged,  generally 
fell,  soon  to  regain  its  original  level.  The  volume  of  the  intestines 
behaved  in  a  similar  manner;  the  venous  pressure  in  just  the  oppo- 
site manner.     From  these  experiments  it  appears  that  auricular 

•  The  Fractional  Method  of  Blood-pressure  Determination,  Arch.  Int.  Med.,  1915, 
xli,  939. 

2  Fibrillation  of  the  Auricles,  its  Effect  upon  the  Circulation,  Jour.  Exp.  Med., 
1912,  xvi,  395. 


254  BLOOD-PRESSURE  IN  CARDTAC  DISEASE 


MM.  HG. 


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10 


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30 


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50 


70 


80  PER  MIN. 


Fig.  96. — Showing  the  relation  of  systolic  and  diastolic  pressures  in  a  typical  case 
of  auricular  fibrillation  in  which  the  diastolic  pressure  of  one  cycle  never  exceeds 
the  systolic  pressure  of  another.  The  numbers  at  the  left  indicate  millimeters  of 
mercury  pressure  in  the  pneumatic  cuff;  those  at  the  bottom  the  rate  per  minute  of 
beats  counted  in  various  ways.  The  upper  line  here  represents  the  results  of  palpa- 
tory systolic  counts,  the  lower  line  fifth  phase  diastolic  counts, 
(a)       (b)      (c)> 

6-0=6  6  X  147.5  =     885 

8-6=2  2  X  142.5  =      285 

14  -    8  =    6  6  X  137.5  =     825 

38  -  14  =  24  24  X  132.5  =  3,180 

60  -  38  =  22  22  X  127.5  =  2,805 

76  -  60  =  16  16  X  122.5  =  1,960 

82  -  76  =    6  6  X  117.5  =      705 

^88  -  82  =    6  6  X  112.5  =      675 


11,320^  88  =  128.6  =  average 

systolic  pressure. 
'  In  the  figures  shown  herewith  the  numbers  on  the  base  line  correspond  to  the 
figures  in  column  a  in  the  above  tabulation;  i.  e.,  they  represent  total  numbers  of 
waves  felt  or  sounds  heard  at  the  corresponding  cuff  pressures.  For  some  purposes 
it  would  be  an  advantage  to  construct  curves  in  which  the  base-line  figures  repre- 
sented the  quantities  in  column  c,  i.  e.,  the  number  of  beats  which  have  a  certain 
pressure.  In  such  a  figure  taken  from  a  normal  case  there  would  be  two  narrow 
curves  separated  by  the  amount  of  the  pulse-pressure,  while  if  it  were  from  a  very 
irregular  case  the  diastolic  and  systolic  curves  might  overlap.  The  work  of  con- 
structing these  additional  curves  is  unnecessary  if  it  is  remembered  that  their  lateral 
extent  would  depend  on  the  slope  of  the  curves  here  employed.  In  the  figures 
herewith,  the  more  uniform  the  pressure  of  the  beats,  the  more  nearly  horizontal 
the  lines,  and  the  more  variable  the  pressure  the  more  sloping  the  lines. 


PRACTICAL  CONST DERATWNS  255 

fibrillation  does  not  necessarily  entail  any  marked  changes  on  the 
circulation  as  a  whole.  In  human  disease,  however,  we  are  dealing 
not  only  with  an  arrhythmia  but  with  a  diseased  myocardium  as 
well,  so  that  marked  differences  are  readily  accounted  for. 

Doubtless  part  of  the  blood-pressure  variations  which  occur  in  as- 
sociation with  various  forms  of  arrhythmia  are  the  result  of  mechan- 
ical respiratory  influences.  While  Henderson  has  emphasized  the 
fact  that  heart-rate  changes  in  man  have  an  important  part  in 
blood-pressure  variations,  and  while  in  some  cases  they  are  the 
only  determining  influence,  yet  this  is,  according  to  Wiggers,^  not 
the  only  nor  even  the  main  factor  in  the  majority  of  cases. 

Practical  Considerations. — Blood-pressure  observations  are  often 
distinctly  useful  in  the  diagnosis  of  valvular  lesions.  A  high  sys- 
tolic and  a  low  diastolic  pressure  suggests  aortic  insufficiency,  the 
murmur  of  which  is  often  low-pitched  and  easily  overlooked.  If 
a  double  aortic  murmur  is  heard,  blood-pressure  readings  will  often 
help  us  in  deciding  whether  the  obstruction  or  the  insufficiency  is 
the  preponderant  lesion.  In  aortic  obstruction  the  pulse-pressure 
is  small.  Again,  in  case  of  a  presystolic  murmur  associated  with 
an  aortic  lesion,  the  sphygmomanometer  may  help  us  in  deciding 
whether  we  are  dealing  with  a  Flint  murmur  or  with  an  additional 
mitral  obstruction.  In  the  latter  case  the  pulse-pressure  is  small 
and  the  systolic  pressure  relatively  normal. 

In  cases  presenting  the  symptoms  of  angina  pectoris  a  high 
blood-pressure  is  evidence  in  favor  of  an  organic  lesion,  although 
the  occurrence  of  a  normal  pressure  by  no  means  excludes  it.  Well- 
marked  hypotension  in  patients  complaining  of  weakness  and  vertigo 
with  dyspnea  on  exertion,  points  to  a  loss  of  vasomotor  tone  rather 
than  to  a  myocardial  lesion  in  which  pressures  are  generally  normal 
or  slightly  increased. 

Many  cardiac  murmurs  in  advanced  life  are  due  to  roughening 
and  sclerosis  of  the  valves,  although  their  actual  functional  capacity 
may  be  but  little  impaired.  Here,  again,  the  absence  of  significant 
pressure  abnormalities  may  help  in  solving  the  problem.  Some 
light  may  also  be  thrown  upon  the  strength  of  the  heart  muscle 
by  the  duration  of  the  different  auscultatory  phases  (see  p.  72). 
A  certain  amount  of  the  increased  tension  seen  in  cardiac  patients 
is  due  to  their  psychic  state  (discomfort,  anxiety,  fear,  etc.).  Jane- 
way  has  suggested  that  a  dose  of  morphin,  which  is  often  followed 
by  marked  and  often  lasting  improvement  in  such  cases,  may 

'  Does  Cardiac  Rhythm  alone  Determine  Blood-pressure  Variations?  Jour.  Exr>. 
Med.,  1914,  xix,  1. 


256  BLOOD-PRESSURE  IN  CARDIAC  DISEASE 

also  show  how  much  of  the  increased  pressure  is  due  to  the  mental 
condition. 

Pericardial  Effusions. — It  has  been  known  ever  since  the  experi- 
ments of  Cohnheim  that  a  rise  of  intrapericardial  pressure  is  followed 
by  a  decreased  aortic  pressure,  and  vice  versa. 

Experimental  Data. — Under  normal  circumstances  the  peri- 
cardium— which  is  in  health  indistensible  and  capable  of  with- 
standing a  pressure  sufficient  to  rupture  the  myocardium — acts  as 
a  protective  covering  to  the  heart  under  conditions  of  strain.  It 
prevents  cardiac  dilatation  beyond  a  certain  point  and  in  so  doing 
adds  measurably  to  the  efficiency  of  the  tricuspid  valve. ^  It  pre- 
vents the  further  inflow  of  venous  blood  when  a  certain  stage  of 
dilatation  has  been  reached,  which,  did  it  not  occur,  would  lead 
to  interstitial  hemorrhage  and  myocardial  rupture.^  It  has  been 
shown  that  when  the  heart  of  a  curari^ed  animal  (cat)  is  enclosed 
in  a  glass  cardiometer  very  small  changes  of  pressure  in  the  cardi- 
ometer  system  produce  comparatively  wide  changes  in  the  carotid 
pressure.  Thus,  an  increase  of  1  mm.  Hg.  of  extracardial  pressure 
caused  a  fall  of  8  mm.  in  the  systolic  pressure.  These  changes 
occur  within  the  space  of  time  occupied  by  two  heart  beats.  If 
intrapericardial  pressure  is  raised  with  the  heart  in  situ  essentially 
similar  results  are  obtained^  (see  p.  44) . 

Clinical  Data. — In  pericardial  effusions  we  therefore  find  a  loivered 
arterial  tension  and  a  decreased  pulse-pressure.  Owing  to  the 
increased  intrapericardial  pressure,  less  blood  reaches  the  right 
auricle,  the  blood  flow  into  which  is  normally  abetted  by  the  fact 
that  extrathoracic  pressure  is  higher  than  that  in  the  venae  cav*. 
Hence  a  smaller  volume  of  blood  reaches  the  left  ventricle;  and 
since  the  systolic  output  is  decreased,  arterial  pressure  must  fall 
unless  these  effects  are  counter-balanced  by  a  peripheral  vasocon- 
striction. These  same  causes  produce  an  increased  verums  pressure 
which  is  compensatory  in  nature;  for  if  venous  pressure  were  to 
fall  below  intrapericardial  pressure  no  blood  would  reach  the  right 
auricle.  Intrathoracic  pressure  being  lower  during  inspiration  and 
higher  during  expiration,  it  is  evident  that  when  venous  and  intra- 
pericardial pressures  are  nearly  equal  the  act  of  breathing  will  have 
an  alternately  inhibiting  and  accelerating  effect  upon  the  blood 
flow  to  the  heart,  which  results  in  the  pulsus  paradoxus — decreased 
volume   during   inspiration.     For  the   reasons   just   stated,   this 

1  Barnard:   Proc.  Jour.  Physiol.,  1898,  xxii,  43. 
*  Kuno,  Y. :    The  Significance  of  the  Pericardium,  ibid.,  1915,  p.  1. 
'  Lewis,  Th. :     The  Influence  of  Intrapericardial  Pressure  upon  the  Inspiratory 
Rise  of  Blood-pressure  in  Vagotomized  Cats,  Jour.  Physiol.,  March  21,  1908,  xxxvii. 


BLOOD-PRESSURE  AS  A  THERAPEUTIC  INDEX         257 

phenomenon  only  occurs  at  a  certain  stage  (broken  compensation), 
and  in  certain  cases  of  pericardial  effusion.^ 

Bronchial  Asthma. — Asthmatic  attacks  are  nearly  always  accom- 
panied by  hypertension.  This  may  result  from  (1)  asphyxia  or 
(2)  complications,  especially  nephritis.  The  act  of  coughing  pro- 
duces a  temporary  marked  increase  of  tension  which  is  coincident 
with  the  expiratory  movement. 

Blood-pressure  as  a  Therapeutic  Index.— The  fact  that  muscular 
efficiency  can  be  increased  by  exercise  and  that  this  rule  applies  to 
the  heart  as  to  other  muscles  was  affirmed  by  Oertel,  who  intro- 
duced graduated  hill  climbing  as  a  therapeutic  measure.  Resisted 
exercises  constitute  a  well-known  part  of  the  Nauheim  treatment. 
Dumb-bell  exercises  have  been  successfully  used  by  Barringer  and 
Tecschner.2  They  employ  certain  flexion  and  extension  movements 
with  dumb-bells  and  bars  of  a  known  weight,  which  renders  an 
approximate  estimation  of  the  work  done  in  foot-pounds  possible. 
The  exercises  which  are  carried  on  for  short  intervals  (30  to  120 
seconds,  with  the  glottis  open,  followed  by  five  minutes  of  rest) 
are  gauged  by  their  effect  upon  blood-pressure  and  pulse  rate.  If 
the  former  falls  and  the  latter  rises,  the  exercise  is  too  severe  and 
must  be  diminished.  The  cases  treated  included  chronic  valvular 
disease  with  varying  amounts  of  decompensation.  Acute  pro- 
cesses, recent  embolism  and  very  high  blood-pressure  were  con- 
sidered as  contra-indications.  Many  of  the  cases  showed  a  marked 
increase  in  efficiency  associated  with  subjective  improvement. 
As  a  rule  the  aortic  cases  (in  young  adults)  improved  more  rapidly 
than  those  with  mitral  disease. 

The  benefits  of  exercise  in  cardiac  disease  are  to  be  attributed 
to  (1)  improved  coronary  circulation;  (2)  increased  peripheral 
blood  flow;  (3)  assistance  to  the  venous  and  (4)  lymphatic,  circu- 
lation; (5)  enlarged  lung  capacity  and  (6)  their  encouraging  psychic 
effect. 

1  Calvert,  W.  J. :  Pulsus  Paradoxus  in  Pericarditis  with  Effusion,  Jour.  Am. 
Med.  Assn.,  1907,  xlviii,  1168. 

*  The  Treatment  of  Cardiac  Insufficiency  by  a  New  Method  of  Exercise  with 
Dumb-bells  and  Bars,  Arch.  Int.  Med.,  1915,  xvi,  795. 


17 


CHAPTER  XI. 

BLOOD-PRESSURE  IN  ARTERIOSCLEROSIS— VASCULAR 

CRISES. 

About  one-third  of  all  cases  of  well-marked  peripheral  arterio- 
sclerosis have  normal  or  subnormal  pressures.  In  the  remaining 
two-thirds  the  pressure  is  variably  increased,  depending  mainly 
upon  the  degree  of  renal  involvement.  Arteriosclerosis  is  selective 
in  its  location;  thus  syphilis  attacks  the  ascending  aorta.  Individ- 
uals who  perform  severe  physical  labor  often  develop  peripheral 
vascular  lesions  of  extreme  degree,  yet  the  pipe-stem  radial  artery 
is  often  a  relatively  benign  type  of  the  disease.  Savill's^  investi- 
gations based  on  400  autopsies  on  individuals  of  and  over  sixty 
years  of  age,  showed  that  extensive  patchy  atheroma  is  consistent 
with  extreme  longevity,  with  an  entire  absence  of  symptoms  or 
of  vascular  complications.  This  same  statement  is  applicable  to 
marked  generalized  intimal  and  adventitial  sclerosis  so  long  as  the 
medial  arterial  wall  is  relatively  uninvolved.  The  foregoing  state- 
ments are  borne  out  by  Ophiils's  studies,^  who  failed  to  find  cardiac 
hypertrophy  in  35  per  cent,  of  all  cases  of  marked  arteriosclerosis. 

The  hypothesis  advanced  by  Hasenfeld  and  Hirsh  that  arterio- 
sclerosis is  unaccompanied  by  increased  blood-pressure  unless  the 
arterioles  in  the  subdiaphragmatic  and  splanchnic  domain  are  the 
seat  of  disease  has  caused  much  discussion  and  is  now  not  generally 
accepted.  Sclerosis  of  either  the  large  or  the  small  splanchnic 
vessels  is  not  a  common  finding.  A  spastic  condition  of  these 
vessels  may  exist,  however,  which  will  increase  tension,  although 
this  is  not  apt  to  occur  once  the  vessels  are  definitely  sclerotic. 

Longcope  and  McClintock^  found  that  compression  of  the 
superior  mesenteric  artery  and  the  celiac  axis  gives  rise  constantly 
to  an  elevation  of  blood-pressure  which  may  last  for  at  least  an 
hour.  This  rise  of  pressure  is  mechanical,  due  not  to  a  reflex  action 
but  to  an  increased  amount  of  blood  in  the  general  circulation. 
The  pressure  remains  increased  until  the  excess  of  blood  accumu- 

>  Lancet,  1904,  p.  506. 

'  Subacute  and  Chronic  Nephritis  as  Found  in  One  Thousand  Unselectcd  Autop- 
sies, Arch.  Int.  Med.,  1912,  ix,  158. 

'  The  Effect  of  Dimini.shed  Blood  Supply  to  the  Intestines  upon  the  General 
Circulation,  Johns  Hopkins  Med.  Bvill.,  1910,  xxi,  No.  234. 


BLOOD-PRESSURE  IN  ARTERIOSCLEROSIS  259 

lates  in  the  ramifications  of  the  splanchnic  vessels  by  way  of  col- 
lateral anastomosis.  But  even  if  this  constriction  is  maintained  for 
several  months  in  dogs  neither  hypertension  nor  cardiac  hyper- 
trophy develop.^  This  may  be  due  to  the  compensatory  effect  of 
an  efficient  collateral  circulation.  Furthermore,  Marchand^  was 
unable  to  establish  any  definite  relationship  between  cardiac  hyper- 
trophy and  the  degree  of  arteriosclerosis  of  the  abdominal  aorta  or 
the  splanchnic  vessels. 

The  evidence  now  at  hand  points  strongly  to  the  view  that 
hypertension  when  present  in  arteriosclerosis  is  due  to  spasm  or 
sclerosis  of  the  systemic  arterioles.  While,  therefore,  the  dictum  that 
a  man  is  as  old  as  his  arteries  still  holds  good,  yet  it  appears  that 
the  condition  of  the  smallest  arteries  is  more  important  than  the 
largest  ones;  and,  further,  we  are  not  justified  in  assuming  that 
because  the  radial  artery  shows  extensive  disease,  the  more  vital 
arteries  and  arterioles  are  therefore  correspondingly  involved. 

Thoma's  injection  experiments  upon  the  cadaver  showed  that 
fluid  could  be  injected  into  arteriosclerotic  much  less  rapidly  than 
into  non-sclerotic  subjects  and,  further,  that  a  much  smaller  quantity 
of  fluid  sufEced  in  the  former  instance  to  produce  edema.  In  other 
words,  although  the  vascular  lumen  is  not  much  reduced  in  size 
the  permeability  of  the  capillaries  is  diminished  and  in  all  probability 
their  area  diminished  while  the  resistance  in  the  arterioles  is 
increased.^ 

The  causes  and  pathology  of  vascular  disease  cannot  be  dis- 
cussed here,  and  only  the  phases  of  the  problem  which  have  a 
distinct  bearing  on  blood-pressure  will  be  considered. 

Osier  states  that  (1)  high  blood-pressure  is  one  of  the  causes  of 
arteriosclerosis — the  others  being  (2)  wear  and  tear,  (3)  infections 
and  (4)  intoxications.  The  following  classification  of  arteriosclerosis 
has  been  suggested  by  Allbutt:  (1)  Toxic:  plumbism,  diabetes, 
infectious  diseases,  notably  syphilis;  (2)  involutionary,  from  senile 
degeneration;  (3)  secondary  following  hypertension. 

Clinically,  such  changes  are  manifested  by  arterial  hypertension, 
cardiac  hypertrophy,  albuminuria,  and  varying  subjective  phe- 
nomena; the  first  of  these  resulting  from  tonic  contraction  of  the 
arterioles  and  capillaries.  With  prolonged  increase  of  pressure  the 
systemic  arteries  at  first  become  thickened  and  hypertrophied.  The 
cerebral  vessels  and  the  aorta  being  less  liberally  endowed  with 

'  The  Effect  of  Permanent  Constriction  of  the  Splanchnic  Arteries  and  the  Asso- 
ciation of  Cardiac  Hypertrophy  with  Arteriosclerosis,  Arch.  Int.  Med.,  1910,  vi,  439. 

2  Verhandl.  Kong.  f.  inn.  Med.,  1904,  xxi,  60. 

3  Mott,  F.  W.:  Albutt's  System  Med.,  vi,  327. 


260 


BLOOD-PRE€SURE  IN  ARTERIOSCLEROSIS 


muscular  tissue  dilate,  and,  either  with  or  without  aneurysmal 
change,  not  infrequently  rupture.  The  vascular  damage  in  these 
cases  is  largely  mechanical,  as  in  occupations  associated  with  hard 
labor,  whereas  arterial  degeneration  in  the  organs,  especially  the 
kidneys,  results  mainly  from  toxic  irritation.  As  a  rule  arterio- 
sclerosis is  unassociated  with  arterial  hypertension.  The  blood- 
pressure  in  arteriosclerosis  is  of  course  higher  than  in  youth,  but 
the  degree  and  the  constancy  of  the  elevation  depend  chiefly  upon 
the  location  and  character  of  the  arterial  changes,  especially  upon 
the  extent  to  which  the  peripheral  arterioles  are  affected.  Exten- 
sive, spontaneous  and  often  unexplainable  variations  of  pressure 
are  of  frequent  occurrence. 

Blood-pressure  in  Old  Age. — In  150  cases  ranging  in  age  between 
sixty-five  and  ninety-five  years,  Bowes^  corroborated  the  earlier 
studies  of  Wildt^  to  the  effect  that  during  very  advanced  years  a 
pressure  previously  high  tends  to  recede.  This  is  shown  in  the 
following  tables: 

The  Average  Blood-pressure  of  Both  Men  and  Women. 


Number 

Systolic 

Diastolic 

Pulse- 

examined. 

pressure. 

pressure. 

pressure. 

G5  to  69  years    .      .      . 

.       .      32 

151 

82 

65 

70  to  74      "... 

.       .      39 

160 

86 

73 

75  to  79      "        .      .      . 

.      .      38 

166 

86 

79 

80  to  84      "        ... 

.      .      27 

175 

84 

83 

85  to  89      "        ... 

.      .       7 

170 

90 

77 

90  to  94      "        ... 

.      .       7 

142 

81 

61 

The  Average 

Blood-pressure  of  the 

Women. 

Number 

Systolic 

Diastolic 

Pulse- 

examined. 

pressure. 

pressure. 

pnssure. 

65  to  69  years     .      .      . 

.       .      21 

154 

83 

71 

70  to  74       "        ... 

.       .      29 

158 

83 

72 

75  to  79      "        ... 

.       .      24 

170 

88 

81 

80  to  84      "        ... 

.       .      16 

183 

85 

91 

85  to  89      "        ... 

.       .        7 

170 

90 

77 

90  to  94      "        ... 

.      .       3 

137 

80 

53 

The  Average 

Blood-pressure  of  the  Men. 

Number 

Systolic 

Diastolic 

Pulse- 

examined. 

pressure. 

pressure. 

pressure. 

65  to  69  years    . 

.      .      11 

145 

81 

63 

70  to  74      "        ... 

.       .      10 

166 

91 

75 

75  to  79      "        ... 

.       .      14 

159 

89 

77 

80  to  84      "        ... 

.      .      11 

163 

84 

80 

85  to  89      "        ... 

.      .        0 

90  to  94      "        ... 

.      .        4 

145 

81 

65 

'  Blood-pressure  in  the  Aged,  Jour.  Lab.  and  Clin.  Med.,  1917,  ii,  No.  4. 
'  Ueber  Blutdruck  im  Greisenalter,  Zentralbl.  f.  Herz.  u.  Gefasskrankh.,   1912, 
\  S.  41-49. 


VASCULAR  REACTIONS  IN  ARTERIOSCLEROSIS         261 

Bilateral  inequality  of  pressure  is  frequent  in  arteriosclerosis, 
and  accuracy  can  only  be  obtained  by  repeated  readings,  inasmuch 
as  temporary  variations  are  common.  Large  pulse-pressures  are 
the  rule,  because  the  diastolic  pressure  remains  disproportionately 
low  compared  to  the  diastolic  level  seen  in  cardiovascular  hyper- 
tension. 

Arteriosclerosis  per  se  does  not  necessarily  cause  hypertension. 
The  actual  height  of  the  pressure  depends  upon  (1)  the  stage  at 
which  the  pressure  is  observed;  (2)  the  degree  of  arteriolar  involve- 
ment; (3)  the  myocardial  integrity.  Some  cases  with  pipe-stem 
arteries  show  relatively  normal  pressures,  while  other  cases  with 
fairly  soft  vessels  show  very  high  tension.  Very  high  pressures 
may  exist  without  symptoms,  but  slight  vertigo,  morning  head- 
ache, numbness,  tingling  and  cramps  in  the  legs  are  to  be  expected. 
All  of  Bowes'  cases  which  suffered  cerebral  hemorrhage  showed 
high  systolic,  diastolic  and  pulse-pressures. 

Vascular  Reactions  in  Arteriosclerosis. — ^The  circulation  in 
arteriosclerosis  differs  in  many  ways  from  that  in  health.  The 
normal  arm,  according  to  O.  Miiller's  plethysmographic  studies, 
contains  about  7  per  cent,  of  blood;  in  arteriosclerosis  this  amount 
is  much  decreased.  Abnormal  local  variations  in  blood-pressure, 
either  unilateral  or  bilateral,  in  corresponding  or  different  regions 
of  the  body  are  not  uncommon  in  arteriosclerosis. 

In  the  case  of  normal  arteries  the  fall  of  pressure  in  passing  from 
the  aorta  to  the  periphery  is  gradual.  The  first  important  fall 
occurs  in  the  capillaries.  In  sclerotic  vessels,  however,  vascular 
contraction  of  the  arterioles  and  small  arteries  is  capable  of  pro- 
ducing well-demonstrable  pressure  differences  in  homologous  per- 
ipheral arteries.  Findlay^  found  that  as  the  age  of  the  subject 
increased  there  was  a  constantly  increasing  tendency  for  marked 
pressure  variations  to  occur  between  the  central  and  peripheral 
arteries,  e.  g.,  brachial  and  digital.  In  the  majority  (80  per  cent.) 
of  the  cases  the  proximal  vessel  showed  the  higher  pressure.  These 
findings  ^^ere  especially  noticeable  in  cases  of  arterial  hN'pertension 
and  are  apparently  due  to  arterial  contraction. 

This  fact  has  been  emphasized  by  Teissier,^  who  believes  that 
these  localized  inequalities  of  pressure  indicate  the  site  of  the  arterio- 

1  The  Systolic  Pressiire  at  Dififerent  Points  of  the  Circulation  in  the  Child  and  the 
Adult,  Quart.  Jour.  Med.,  1910,  iv,  489.  See  also  Pesci:  Riforma  Medica,  June 
7,  1909. 

'  R61e  des  Hypertensions  partielles  dans  les  determinations  symptomatiques  de 
rarteriosclerose,  Bull.  d.  I'Acad.  de  M6d.,  February  25,  1908,  Ixxii. 


2G2  BLOOD-PRESSURE  IN  ARTERIOSCLEROSIS 

sclerotic  process.  Thus,  if  the  splanchnic  vessels  are  chiefly  affected, 
hypertension  is  said  to  occur  in  the  dorsalis  pedis  artery,  while 
increased  tension  in  the  temporal  or  the  radial  arteries  points 
respectively  to  involvement  of  the  intracranial  or  the  intrathoracic 
vessels.  This  he  explains  as  due  to  a  segmental  phenomenon  to 
which  the  peripheral  and  the  deep-seated  arteries  react  similarly. 
In  one  case  increased  pressure  in  the  temporal  artery  was  soon 
followed  by  the  appearance  of  glaucoma  on  the  same  side.  In 
another  case  a  similar  pressure  increase  preceded  attacks  of  facial 
paralysis,  vertigo,  and  apoplectiform  manifestations. 

These  observations  are  of  great  interest  but  must  be  accepted 
with  considerable  reserve  on  account  of  the  possibility  of  instru- 
mental error.  The  normal  pressures  as  obtained  with  the  Potain 
apparatus,  which  Teissier  used,  are  16  to  18  cm.  in  the  radial;  13 
to  15  in  the  dorsalis  pedis;  and  8  to  12  cm.  in  the  temporal  arteries. 
Even  if  careful  allowances  are  made  for  postural  variations,  the 
unavoidable  margin  of  error  would  often  be  greater  than  the  actual 
supposedly  abnormal  pressure  variations.  (See  also  under  Func- 
tional Tests.) 

Inequality  of  the  pressure  of  the  pulse  on  the  two  sides  of  the 
body  (5  to  15  mm.),  if  constantly  present  and  not  attributable  to 
any  local  abnormality,  often  points  to  arteriosclerotic  changes. 
Engel^  believes  that  this  sign  may  be  useful  in  diagnosticating 
between  primary  nephritis  and  arteriosclerosis.  (See  Aortic 
Aneurysm.) 

Recent  observations  of  Pierret  made  with  the  Pachon  apparatus 
on  the  pressures  of  the  radial  and  tibial  arteries  have  shown  in  17 
out  of  20  cases  higher  readings  in  the  lower  limb  (30  mm.  systolic, 
10  mm.  diastolic).  Heitz^  found  that  the  arm  and  leg  readings 
differ  very  considerably,  depending  on  the  size  of  the  cuff  employed 
and  whether  the  Pachon  or  the  Riva-Rocci  instruments  are  used. 

The  rapidity  of  transmission  of  the  pulse  warn  depends  upon  both 
the  condition  of  the  vascular  wall,  and  to  a  less  extent  upon  the 
height  of  blood-pressure.  The  normal  rate  is  8.3  to  12  m.  per  second. 
In  arteriosclerosis  the  rate  has  been  found  increased  to  10.1  m. 
(Friberger^),  23  m.  (Miinzer).^     In  dicrotic  pulses  the  transmission 

'  Berl.  klin.  Wchnschr.,  September  20,  1909,  xlvi. 
•     2  Dos  Mensurations  de  Pression  dans  les  Art^res  des  Membres  Inferieures,  Archiv. 
des  maladies  du  cneur  des  Vaisseaux  et  du  Sang,  April,  1913,  p.  285. 

'  Pulswellengeschwindigkeit  bei  Arterien  m.  flihlbarer  Wandverdiekung,  Deutseh. 
Arch.  f.  klin.  Med.,  1912,  cvii,  280. 

*  Die  Forti)flanzungsgcschwindigkeit  der  Pulswellen  in  Gesunden  u.  krankhaft 
veranderten  Blutgefassen,  Kong.  inn.  Med.,  1912,  xxix,  431. 


VASCULAR  REACTIONS  IN  ARTERIOSCLEROSIS         263 

is  delayed.  This  rapid  transmission  of  the  pulse  wave,  associated 
with  a  relatively  low  diastolic  pressure  often  leads  one  to  over- 
estimate the  vigor  of  the  pulse.  The  rapidity  of  pulse  transmission 
in  different  valvular  defects  depends  far  more  upon  the  degree  of 
tension  and  of  arteriosclerosis  than  upon  the  character  of  the 
lesion.^     (See  Aortic  Insufficiency,  p.  242.) 

The  Nitrite  Test. — Rzentkowski^  found  in  healthy  subjects  only 
a  slight  and  brief  diastolic  fall  after  the  inhalation  of  amyl  nitrite. 
In  arteriosclerosis,  on  the  other  hand,  much  greater  and  more  pro- 
longed lowering  occurred  despite  increased  cardiac  activity.  He 
interprets  these  facts  as  indicating  that  the  splanchnic  vessels  have 
lost  their  compensatory  contractility,  which  in  normal  individuals 
prevents  much  disturbance  of  tension.  Arteriosclerotic  hyper- 
tension may  therefore  (since  the  peripheral  vessels  still  retain  their 
power  of  dilating)  be  regarded  as  due  to  prolonged  contraction  of  the 
arterioles.  Whether  this  explanation  be  correct  or  not  the  practi- 
cal procedure  may  be  of  some  value  as  a  test  of  arterial  functiona- 
tion.  F.  Franck  states  that  permanent  hypertension  cannot  be 
due  to  vasoconstriction,  a  muscular  spasm  which  he  believes  can- 
not persist  indefinitely.  He  calls  attention  to  the  fact  that  vaso- 
constriction in  one  locality  is  sooner  or  later  always  counterbal- 
anced by  vasodilatation  elsewhere. 

The  Stasis  Reaction. — The  blood-pressure  is  taken  in  the  recum- 
bent posture  by  the  auscultatory  method.  Following  this,  the 
circulation  in  three  extremities  is  occluded  by  inflation  of  rubber 
cuffs.  This  procedure  in  normal  individuals  when  maintained  for 
five  minutes  usually  produces  a  rise  of  pressure  of  from  5  to  10 
mm.  Hg.  In  arteriosclerotics  the  usual  average  reaction  is  27  mm., 
the  maximum  60.  An  increase  of  pressure  under  these  circum- 
stances therefore  points  to  arteriosclerosis.  Its  absence  does  not 
exclude  this  condition  (Hertzell).^ 

The  Ice  Reaction. — Romberg  and  his  pupils  have  shown  that  the 
application  of  ice  to  the  arm  normally  produces  a  diminished  local 
blood  flow.  In  arteriosclerosis  this  reflex  tends  to  be  abolished. 
A  merely  hypertrophic  artery  may,  however,  show  a  normal  or 
even  an  increased  response.     (See  under  Function  Tests,  p.  180.) 

'  Beitriig  z.  Lehre  v.  d.  Fortpflanzungsgeschwindigkeit  d.  Pulswellen  b.  gesunden 
u.  kranken  Individuen,  Samml.  wiss.  Arb.  1,  Langensalze,  Wendt  and  Klauwell, 
1912,  p.  39. 

2  Untersuchungen  u.  d.  Wirkung  des  Amylum  nitrosum  auf  d.  gesunde  u.  sklero- 
tische  Arteriensysteni,  Ztschr.  f.  klin.  Med.,  1909,  xlviii.  111. 

'  Die  Stauungsreaktion  bei  Arteiiosclerose,  Berliner  klin.  Wchnschr.,  1913,  1,  S. 
535-538. 


264  BLOOD-PRESSURE  IN  ARTERIOSCLEROSIS 

The  Arteriocapillary  Pressure  Index. — Fink^  maintains  that  there 
is  a  definite  and  characteristic  relationship  between  arterial  and 
capillary  pressure  in  arteriosclerosis.  If  an  index  is  established 
thus : 

arterial  pressure  17-18  cm.  Hg.    (Potain) 


capillary  pressure  9-10  cm.         (Gartner) 


=  1.80  -  2 


the  quotient  will  lie  normally  between  1.5  and  2.  According  to 
Fink  we  obtain  in  arteriosclerosis  an  index  below  1.5,  sometimes 
below  1.  The  smaller  the  quotient  the  more  marked  the  evidences 
of  circulatory  insufficiency — dyspnea,  edema,  etc.  But  he  specific- 
ally asserts  that  this  is  an  index  of  circulatory  efficiency  and  not 
one  of  anatomical  integrity.  These  observations  would  have  more 
value  if  the  factor  of  instrumental  error  could  be  reduced. 

In  normal  individuals  the  local  application  of  heat  to  the  hand 
produces  a  fall  of  the  brachial  and  a  rise  of  the  digital  pressures. 
In  arteriosclerotics  negative  or  atypical  reactions  are  generally 
observed  (Dobrymin). 

VASCULAR  CRISES. 

The  term  vascular  crises  was  coined  by  Collier.  The  subject  has 
been  elaborately  studied  by  PaP  and  others,  who  class  under  this 
heading  conditions  which  result  from  local  or  general  (1)  vaso- 
contraction,  (2)  vasodilatation,  which  arise  without  demonstrable 
anatomical  lesions,  the  symptoms  thus  produced  disappearing  when 
normal  vascular  relations  are  reestablished. 

It  is  a  self-evident  fact  that  vasomotor  stability,  control,  and 
compensation  are  among  the  most  fundamental  attributes  of  the 
animal  economy.  Furthermore,  these  intervascular  relations  must 
be  adjusted  and  balanced  to  an  extreme  point  of  sensitiveness  and 
delicacy.  It  is  not  surprising  when  one  considers  these  facts,  that 
vasomotor  incoordination  should  occur,  especially  under  certain 
conditions  which  appear  to  predispose  to  it. 

Jt  has  been  clearly  established  that  certain  vascular  domains 
are  controlled  by  definite  vasomotor  centres,  as  the  mesenteric 
vessels  by  the  splanchnic  nerves.  It  furthermore  appears  likely 
that  the  enervation  of  such  a  system  may  be  disturbed  in  part 
after  the  manner  of  segmental  distribution,  and  also  that  the  dis- 
turbances may  be  limited  to  the  vasomotor  element  alone.    There 

1  Nouvelles  recherches  sur  la  valeur,  du  rapport  des  tensions  art^rielles  et  capillaires 
dans  rart6rioscl6rose,  Rev.  de  M6d.,  August,  1908,  p.  747. 
'  Gefasskrisen,  Leipsic,  1905. 


VASCULAR  CRISES  265 

exists  also  a  definite  reciprocal  relationship  between  certain  vascular 
areas,  by  virtue  of  which  a  contraction  in  one  produces  a  dilatation 
of  the  other.  This  phenomenon  has  been  ascribed  by  some  to  active 
vasodilatation,  by  others  to  a  purely  mechanical  displacement  of 
blood. 

A  vascular  crisis  may  be  brought  about  by  an  abnormal  (1) 
contraction,  or  (2)  dilatation,  in  a  given  vascular  domain,  which 
results  in  a  certain  train  of  direct  or  indirect  symptoms  which  may 
manifest  themselves  in  the  immediate  neighborhood  or  at  a  distance 
from  the  seat  of  the  vascular  abnormality,  or  in  general  vascular 
phenomena.  Certain  conditions  appear  to  predispose  to  such  vas- 
cular crises,  notably  arteriosclerosis,  nephritis,  pregnancy,  tabes,  and 
plumbism.  The  actual  symptoms  produced  will  depend  upon  (1) 
the  vascular  domain  involved;  (2)  whether  vascular  spasm  or  dila- 
tation exists;  (3)  whether  these  changes  are  compensated  for  in 
other  vascular  domains;  (4)  to  what  extent  the  function  of  the 
part  or  organ  is  affected,  etc.  The  existence  of  local  vascular 
crises  has  been  indubitably  demonstrated  in  spasmodic  contraction 
of  the  central  retinal  artery  (see  p.  433). 

I.  Crises  due  to  Vasoconstriction. — (a)  The  pectoral  type,  (6) 
the  abdominal  type,  (c)  the  cerebral  form,  (d)  the  crises  of  the 
extremities  (peripheral  form),  (e)  the  general  vascular  type,  (/) 
paroxysmal  dyspnea. 

The  exact  cause  and  mechanism  of  these  vascular  abnormalities 
is  not  easy  to  determine.  It  cannot  be  sought  primarily  in  the 
anatomical  abnormalities  of  the  arteries  in  question,  because  the 
spastic  phenomena  are  often  manifested  in  vascular  areas  which 
are  not  essentially  diseased  or  primarily  affected.  It  may  be  (1) 
that  stimuli  which  arise  in  the  diseased  area  exert  their  influence 
upon  other  domains;  (2)  that  the  sympathetic  system  is  called  into 
play  by  local  abnormalities  in  the  vaso  vasorima;  or  (3)  that  some 
pressor  substance  gains  entrance  into  the  blood  stream. 

Angina  Pectoris — Although  there  is  still  much  doubt  regarding 
the  genesis  of  angina  pectoris,  there  can  be  no  uncertainty  that 
many  if  not  all  cases  are  closely  allied  to  vascular  spasm.  Whether 
such  a  contraction  is  purely  local — limited  to  the  coronary  arteries 
— thus  causing  ischemia  of  the  myocardium,  or  whether  it  be  of  a 
more  general  nature,  cannot  be  definitely  stated.  Angina  pectoris 
is  sometimes  associated  with  Raynaud's  disease  and  intermittent 
claudication,  both  of  which  are  typical  examples  of  local  vascular 
spasm.  The  writer  was  on  one  occasion  taking  a  blood-pressure 
reading  during  which  an  attack  of  angina  occurred.    The  systolic 


2G6  BLOOD-PRESSURE  IN  ARTERIOSCLEROSIS 

pressure,  previously  160  mm,  Hg.,  suddenly  rose  to  210  mm.  and 
remained  at  that  point  for  the  few  minutes  during  which  the  pain 
lasted.  In  many  cases  of  angina,  however,  the  pressure  during 
attacks  is  either  normal  or  actually  lowered.  The  latter  occurs 
especially  in  the  syphilitic  case!>  and  is  what  one  should  expect  if 
coronary  arterial  spasm  is  accepted  as  the  cause  of  the  attacks.  It 
is  also  to  be  remembered  that  both  pain  and  anguish  have  potent 
pressor  actions  and  that  a  rise  of  pressure  when  present  may  be  the 
result  and  not  the  cause  of  the  paroxysm. 

Anginal  attacks  may  be  preceded  by  or  associated  with  evidences 
of  local  peripheral  vascular  crises — pallor,  coldness,  cyanosis.  "  It 
is  probable  that  by  disease  of  the  aorta  its  sensitive  endowments, 
those  which  regulate  blood-pressure,  are  disordered — exalted  or 
impaired;  and,  during  or  near  the  attack,  pain,  dread  or  distress 
make  all  measurements  of  blood-pressures  untrustworthy."^  Tran- 
sient aphasia,  paralysis,  dead  fingers,  etc.,  which  are  also  angio- 
spastic phenomena,  may  also  occur  coincidently  with  the  par- 
oxysms.2  Furthermore,  angina  pectoris  and  abdominalis  may  be 
alternately  present  in  the  same  patient,  and  the  symptoms  of  the 
latter  are  closely  analogous  to  the  abdominal  vascular  crises  of 
plumbism,  locomotor  ataxia,  angioneurotic  edema,  and  purpura. 
Curschmann^  has  reported  cases  illustrating  the  development  of 
angina  pectoris  upon  a  basis  of  or  as  an  accompaniment  to  peripheral 
vasomotor  cramps,  emphasizing  the  fact  that  the  heart  is  embryo- 
logically  only  a  specialized  artery,  so  that  its  connection  with  the 
arteries  is  both  anatomical  and  nervous. 

The  subjects  of  angina  pectoris  are  the  subjects  of  arterial  dis- 
ease— aortic,  coronary,  or  general — and  sclerotic  arteries  readily 
exhibit  spastic  manifestations.  Most  of  these  patients  have  previ- 
ously had  arterial  hypertension  for  variable  periods.  During  the 
paroxysms  the  pressure  suddenly,  markedly,  and  rapidly  increases. 
While  the  rise  may  be  abetted  by  the  pain  it  is  certainly  not  pri- 
marily caused  by  it,  and  it  is  often  relieved  by  amyl  nitrite.  "In 
many  cases  the  attack  begins  directly  as  a  peripheral  vasocon- 
strictor storm,  with  cold  hands  and  cold  feet,  pallor  of  the  face, 
and  sweating.  Nor  is  this  simply  in  the  so-called  functional  type, 
but  in  the  severest  forms  an  emotional  disturbance  may  initiate  a 
widespread  contraction  of  the  arteries.     During  the  paroxysm  it 

'  Albutt,  C:  Diseases  of  the  Arteries  Including  Angina  Pectoris,  London,  1915, 
ii,  338. 

^  Osier,  Sir  William:     Angina  Pectoris,  Lancet,  March  12  and  26,  and  April  9,  1910. 
'  Deutsch.  nied.  Wchnschr.,  1906,  xxxii,  38. 


VASCULAR  CRISES 


267 


is  by  no  means  uncommon  to  find  the  radial  pulse  on  one  side  much 
smaller  than  on  the  other"  (Osier). 

Many  but  not  all  cases  of  angina  pectoris  show  marked  hyper- 
tension (190  to  220  mm.).  The  presence  of  increased  pressure  is 
often  the  best  indication  of  an  organic  lesion,  but  its  absence  (150 
to  160  mm.)  cannot  be  accepted  as  evidence  of  a  mere  functional 
or  digestive  disturbance.  The  following  table  shows  the  blood- 
pressure  findings  in  cases  of  angina  pectoris  seen  by  the  writer  in 
private  and  consultation  practice : 


No. 

Age. 

Blood-pressure. 

Outcome. 

1     ...     72 

185  and    75 

Death  in  paroxysm. 

2 

73 

200     ' 

'    115 

Death  in  paroxysm. 

3 

49 

140     ' 

'    100 

Death  from  rupture  of  ventricle 

4 

60 

160     ' 

'    110 

Unknown. 

5 

66 

200     ' 

'    130 

Unknown. 

6 

68    • 

138     ' 

'    120 

Unknown. 

7 

42 

200     ' 

'    110 

Unknown. 

8 

58 

200     ' 

'    165 

Death  in  paroxysm. 

9 

59 

190     ' 

'    100 

Unknown. 

10 

53 

150     ' 

'    100 

Living,  free  from  symptoms. 

11 

70 

195     ' 

'    100 

Death  in  paroxysm. 

12 

68 

195     ' 

'      85 

Death  in  paroxysm. 

13 

62 

225     ' 

'    170 

Death  from  apoplexy. 

14 

72 

160     ' 

'      ? 

Death  sudden,  third  attack. 

Angina  Abdominalis — the  abdominal  counterpart  of  angina 
pectoris — is  more  or  less  closely  associated  with  the  clinical  picture 
of  abdominal  arteriosclerosis.  It  is  based  upon  the  presence  of 
periarteritis,  local  thrombosis,  or  vascular  spasm  of  the  mesenteric 
artery,  and  has  been  regarded  as  an  intermittent  dysperistalsis 
(Schnitzler,  Ortner) .  The  clinical  manifestations  consist  of  local 
abdominal  pain,  tenderness,  tjinpanites,  and  of  hypertension. 
Spasm  of  the  iliac  or  femoral  arteries  leads  to  intermittent  claudi- 
cation. Disproportionately  increased  femoral  blood-pressure  has 
been  described  by  French  authors  in  association  with  acute 
abdominal   aortitis. 

Paroxysmal  epigastric  pain  in  arteriosclerotic  subjects  is  not 
uncommon  and  frequently  results  from  organic  changes  in  the 
gastro-intestinal  tract.  These  attacks  are  sometimes  brought  on 
by  overexertion,  overeating,  emotional  disturbances,  or  by  lying 
down. 

Buch^  distinguishes  two  classes  of  arteriosclerotic  abdominal 
pain:  (a)  abdominal  cramp;  (6)  angina  abdominalis.  The  clinical 
manifestations  of  the  former,  tympanites,  constipation  and  pain, 


1  St.  Petersburger  med.  Wchnschr.,  1904,  xxix,  No.  27;  Arch.  f.  Verdauungskrankh., 
1904,  X,  6. 


268  BLOOD-PRESSURE  IN  ARTERIOSCLEROSIS 

are  associated  with  autopsy  findings  indicative  of  intestinal  paresis, 
due  to  ischemia.  In  angina  abdominahs  the  pain  may  begin  in 
the  epigastrium  and  remain  localized  there. 

The  abdominal  crises  of  angioneurotic  edema  and  purpura,  a 
number  of  which  have  been  attacked  by  the  surgeons, as  a  result 
of  a  mistaken  diagnosis,  have  shown  only  local  visceral  edema  or 
hemorrhage. 

Paroxysmal  dilatation  of  the  abdominal  aorta  is  a  condition  which 
occurs  chiefly  in  run-down,  emaciated,  neurasthenic  women  with 
ptosis  of  some  or  all  of  the  abdominal  organs.  The  condition  is 
characterized  by  an  abrupt  forcible  pulsation  of  the  abdominal 
aorta,  which  is  objectively  visible  and  of  which  the  patient  is  sub- 
jectively conscious.  Associated  with  this  there  may  be  vomiting, 
epigastric  pain,  and  sometimes  faintness.  The  condition  may 
slightly  simulate  aneurysm.  The  attacks  end  as  suddenly  as  they 
begin,  the  termination  being  associated  with  the  disappearance  of 
pain  and  empty  feelings  in  the  epigastrium.  They  may  last  hours 
or  days  and  during  the  attack  blood-pressure  generally  is  elevated 
30  or  40  mm.    Between  paroxysms  pressure  is  normal.^ 

Tympanites — ^The  subjects  of  cardiovascular  disease  complain 
greatly  of  tympanites.  Not  only  is  flatulence  a  frequent  symptom 
among  them,  but  very  slight  degrees  of  distention  cause  a  dispro- 
portionately great  amount  of  discomfort.  How  often  the  subject 
of  angina  pectoris  complains  only  of  his  "stomach." 

The  subject  is  complex.  Undoubtedly  vagus  effects  are  account- 
able for  both  conditions,  but  it  is  further  clear  that  abdominal 
distention  mechanically  interferes  with  heart  action.  Further, 
Stadler  and  Hirsch^  showed  experimentally  that  inflation  of  the 
bowel  from  the  rectum  causes  a  marked  rise  in  blood-pressure. 
This  may  be  due  to  a  hindrance  of  the  abdominal  venous  circula- 
tion, but  more  probably  results  from  dyspnea,  as  it  occurs  coinci- 
dently  with  the  rise  of  the  diaphragm  and  fails  to  appear  if  the 
animals  are  curarized  or  if  artificial  respiration  is  practised. 
Funder's  investigations  indicate  that  reflex  rather  than  purely 
mechanical  causes  are  responsible  for  the  symptoms  (see  p.  43). 
Burton-Opitz  has  shown  that  distention  of  the  intestine  alone 
may  cause  a  great  diminution  of  the  blood  flow  in  the  mesenteric 
vessels'  (see  pp.  192  and  318). 

1  Schlesinger:     Deutsch.  med.  Wchnschr.,  August  22,  1912,  No.  34,  p.  1592. 

2  Meteorismuss  u.  Kreislauf :     Mitt.  u.  d.  Grenz.  d.  Med.  u.  Chir.,  xv,  3  and  4. 

» Burton-Opitz,  R. :  Ueber  d.  Stromung  dea  Blutes  in  dem  Gebiete  d.  Pfortader, 
Arch.  f.  d.  ges.  Physiol.,  1908,  cxiv,  479. 


VASCULAR  CRISES  269 

Renal  and  Biliary  Colic. — Attacks  of  renal  and  biliary  colic  may 
be  associated  with  marked  increase  in  arterial  pressure,  a  phe- 
nomenon which,  while  partly  due  to  pain,  is  probably  the  result  of 
reflex  vasomotor  constriction.  This  sudden  increase  of  tension 
may  account  for  the  production  of  cardiac  murmurs  which  have 
been  reported  as  occasionally  coincident  with  such  attacks.* 

Cerebral  Vascular  Crises. — The  nervous  phenomena  of  hyperten- 
sion include  headache,  vertigo,  convulsive  seizures,  paralyses  (mono- 
plegia, hemiplegia),  aphasia,  dementia,  etc.  These  symptoms  may 
occur  spontaneously  and  after  lasting  for  a  few  hours  disappear 
almost  as  suddenly  as  they  appeared.  The  generally  accepted  belief 
at  present  is  that  they  are  due,  as  was  first  suggested  by  George 
Peabody,^  to  local  vascular  spasm.  Organic  lesions,  hemorrhages 
or  edema  may  perhaps  also  produce  only  transient  effects,  but  the 
duration  in  such  cases  is  longer  and  the  recovery  more  gradual. 
Intermittent  closing  and  opening  of  the  cerebral  vessels  is  by  far 
the  most  tenable  hjqjothesis  upon  which  to  explain  brief,  tem- 
porary attacks  of  paralysis.  Sir  William  Osler,^  who  has  reported 
two  very  dramatic  cases,  states  that  temporary  aphasia  is  one  of 
the  commonest  of  these  transient  manifestations.  "Inability  to 
talk,  the  consciousness  of  it,  no  paralysis,  emotional  disturbance 
and,  within  a  few  hours,  complete  recovery,"  are  characteristic. 
As  high  as  twenty  such  attacks  may  occur  before  the  patient  suc- 
cumbs to  some  of  the  eventualities  of  arteriosclerosis.  With  the 
disappearance  of  symptoms  the  pressure  falls  (often  30  to  50  mm.) 
to  the  patient's  normal  level. 

Vertigo  is,  according  to  Finkelnberg's*  investigations,  generally 
associated  with  an  increase  of  the  minimum  pressure  and  a  decrease 
of  the  blood-pressure  quotient.  This  diminution  of  pulse  volume 
which  is  often  associated  with  pallor,  weakness,  and  syncope 
apparently  results  from  cerebral  anemia.  Vertigo  may  occur  in 
either  high-  or  low-tension  cases  as  a  result  of  cerebral  anemia.  It 
has  been  suggested  that  rotary  vertigo  of  labyrinthine  origin  always 
results  from  bilaterally  unequal  vasomotor  influences  along  some 
portion  of  the  coordinating  tracts,* 

1  Riesman,  D. :  Cardiac  Murmurs  during  Attacks  of  Biliary  Colic,  Am.  Jour. 
Med.  Sc,  November,  1911. 

'  Tr.  Assn.  Am.  Phys.,  1891,  vi,  170. 

» Transient  Attacks  of  Aphasia  and  Paralysis  in  States  of  High  Blood-pressure 
and  Arteriosclerosis,  Canadian  Med.  Assn.  Jour.,  October,   1911. 

*  Ueber  Blutdruckmessung  bei  Schwindel,  Miinchen.  med.  Wchnschr.,1906,  lii,  238. 

'Fowler,  E.  P.:  The  Origin  of  Labj-rinthine  Rest-tone,  Jour.  Am.  Med.  Assn., 
1915,  Ixiv,  118. 


270  BLOOD-PRESSURE  IN  ARTERIOSCLEROSIS 

Apoplexy. — Vascular  rupture  is  naturally  more  apt  to,  occur  if 
blood-pressure  changes  in  addition  to  being  great  are  sudden. 
The  marked  pressure  effects  of  violent  muscular  action,  especially 
when  associated  with  volitional  effort  or  psychic  stimulation  have 
been  alluded  to.  It  is  not  surprising,  therefore,  to  find  that  fits 
of  anger,  fright,  sudden  stooping  or  heavy  lifting,  especially  after 
a  full  meal,  straining  at  stool,  coitus,  etc.,  are  often  the  precipi- 
tating causes  of  vascular  rupture  and  anginal  attacks.  The  history 
of  a  preceding  transient  hemiplegic  attack  is  not  infrequently 
obtained  in  cases  that  ultimately  succumb  to  apoplexy  (see 
Hemiplegia) . 

Peripheral  Vascular  Crises— This  group  includes  intermittent 
claudication,  erythromelalgia,  and  Raynaud's  disease.  In  each  case 
there  is  believed  to  be  a  disturbed  balance  between  the  vasodilator 
and  the  vasoconstrictor  nerves. 

There  is  reason  for  believing  that  some  of  these  cases  owe  their 
origin  to  an  undue  excitability  or  exhaustion  of  the  sympathethic 
nervous  system.  In  a  case  reported  by  Zweig^  there  were  acute 
hallucinations,  recurring  urticaria,  and  sudden  symptoms  of  hyper- 
thyroidism. These  symptoms  bore  no  direct  relation  to  each  other 
but  were  all,  it  seemed,  different  expressions  of  sjnipathetic  lability, 
due  perhaps  to  some  abnormality  of  the  internal  secretions,  thus 
differing  from  the  true  exophthalmic  goitre  cases  in  which  the 
thyroid  syndrome  is  primary.  The  results  of  studies  in  this  class 
of  cases  reported  by  different  investigators  have  been  quite  vari- 
able. Curschmann^  found  that  psychic  and  thermic  stimuli  failed 
to  produce  plethysmographic  reactions.  Stewart^  found  that  the 
application  of  cold  was  followed  by  an  increased  instead  of  a  dimin- 
ished flow;  and  Simons^  has  reported  great  variability  and  asym- 
metry of  vascular  respon'se.  In  Raynaud's  disease  it  is  believed 
that  the  arterioles  are  so  contracted  that  blood  flow  is  practically 
occluded.  Experimental  evidence  proves  that  this  is  quite  pos- 
sible. Macwilliam  and  Kesson^  have  shown  that  an  occlusive 
spasm  capable  of  resisting  a  pressure  of  440  mm.  Hg.  may  occur  in 
diseased  arteries  as  large  as  the  metacarpal  and  metatarsal  of  the 

'  Zur  Kasuistik  u.  Aetiologie  vasomotorischtrophischer  Storungen,  Berl.  klin. 
Wchnschr.,  1912,  xlix,  2268. 

^  Untersuchungen  ueber  d.  funktionelle  Verhalten  d.  Gefasse  bei  tropischen  u. 
vasomotorischen  Neurosen,  Milnchen.  med.  Wchnschr.,  1907,  liv,  2519. 

'  The  Measurement  of  Blood  Flow  in  the  Hands,  Heart,  1911,  iii,  33. 

*  Plethysphygmographische  Untersuchungen  d.  Gefassreflexe  bei  Nervenkranken, 
Arch.  f.  Anat.  u.  Physiol.  Phys.,  Abteil.  1910,  Supplement,  Band  ccccxxix. 

6  Heart,  1913,  iv,  298. 


VASCULAR  CRISES  271 

horse.  Balaauw^  has  commented  on  the  fact  that  spasm  of  the 
retinal  vessels  in  cases  of  Raynaud's  disease  has  probably  never 
been  authentically  reported. 

II.  Angioneurotic  Manifestations. — Abnormal  vascular  responses 
to  stimuli  produce  a  number  of  different  s;yTnptoms  which  have 
been  designated  by  Cohen  as  vasomotor  ataxia.  To  this  group 
belong  dermographism,  urticaria,  angioneurotic  edema,  chilblains, 
etc.  A  patient  studied  by  Hewlett^  who  had  dermographism  and 
chilblains  reacted  to  the  local  application  of  moderate  cold  (which 
precipitated  his  s^nnptoms)  by  a  definitely  increased  blood  flow  in 
the  arm  exposed  in  comparison  to  its  fellow.  The  normal  reaction 
to  cold  is  of  course  just  the  reverse  of  this.  The  exudation  may  be 
serous  or  sanguineous,  but  in  either  case  a  marked  local  vasomotor 
disturbance  exists.  Osier  has  suggested  that  this  group  of  ailments 
are  all  due  to  different  degrees  of  the  same  poison. 

Abnormal  local  vasomotor  phenomena  are  also  exemplified  by 
(1)  the  tdche  cerebrale — a  red  line  with  white  margins,  produced  by 
irritating  the  skin  by  drawing  the  finger-nail  across  it.  This  is  seen 
in  meningitis,  typhoid  fever,  etc.  (2)  The  white  line  of  adrenal 
insufficiency;  a  localized  blanching  of  the  abdominal  skin  pro- 
duced by  means  of  the  finger-nail,  seen  in  Addison's  disease  and 
other  conditions  associated  with  low  blood-pressure.  It  is  directly 
due  to  local  reflex  capillary  spasm.  Neither  of  these  two  conditions 
is  constant,  nor  diagnostically  of  much  importance. 

Vascular  Crises  in  Children. — ^While  vascular  crises  are  chiefly  seen 
in  arteriosclerotic  individuals,  angiospastic  manifestations  have 
also  been  described  in  children.  Thus  Kirsch^  has  reported  attacks 
of  localized  gastric  pain,  associated  with  a  heaving  cardiac  impulse, 
tortuous  carotids,  and  a  tense  and  pulsating  abdominal  aorta, 
which  he  attributes  to  vascular  spasm.  Hamburger  also  calls  atten- 
tion to  certain  subjective  sjniptoms  relating  to  the  heart,  and  to 
objective  vascular  manifestations  due  to  this  cause.* 

Under  the  former  are  found  palpitation,  unpleasant  sensations 
in  the  precordium,  such  as  a  "stitch,"  and  a  feeling  of  oppression. 
Palpitation  occurs  after  physical  exertion  and  to  a  less  degree  after 
psychical  disturbances.  In  marked  cases  more  or  less  pain  and 
dyspnea  may  occur,  and  even  sjTnptoms  comparable  to  the  angina 
pectoris  of  adult  life.    These  sj-mptoms  are,  however,  rare  in  com- 

1  Die  Augen-symptome  d.  Raynaudschen  Krankheit,  Augenheilk.,  1913,  ix.  Heft  5. 

2  Active  Hyperemia  following  Local  Exposure  to  Cold,  Arch.  Int.  Med.,  1913, 
xi,  507. 

'  Gefiisskrisen  im  Kindesalter:  Mitteil.  d.  Gesellsch.  f.  inn.  Med.  u.  Kinderheilk. 
Wien,  1912,  ii,  S.  190-194. 

<MQnchen.  med.  Wchnschr.,  1911,  Iviii,  2201. 


272  BLOOD-PRESSURE  IN  ARTERIOSCLEROSIS 

parison  to  palpitation.  Objectively  there  is  found  a  heaving  some- 
what diffused  apex  beat,  and  slight  epigastric  pulsation.  The 
boundaries  of  the  heart  are  normal,  or  but  slightly  increased;  the 
sounds  are  clear.  The  epigastric  pulsation  is,  in  Hamburger's 
opinion,  due  to  the  descending  aorta  and  not  to  the  right  ventricle. 
The  lability  of  the  pulse  is  shown,  on  the  one  hand,  by  a  rapid 
increase  in  the  rate  on  sitting  up,  standing,  and  on  slight  physical 
exertion;  and  on  the  other  hand,  by  sinus  arrhythmia,  increasing 
with  inspiration  and  diminishing  with  expiration.  This  symptom 
is  most  marked  in  severe  cases,  but  also  occurs  in  normal  children. 
Among  the  subjective  circulatory  symptoms  are  headache,  similar  in 
onset  to  migraine,  but  involving  both  sides  of  the  head,  usually  in 
the  occipital  region.  Sudden  local  anemias  of  the  brain  cause 
dizziness  and  unconsciousness,  these  symptoms  and  the  headache 
being  due  not  to  a  general  anemia,  as  is  often  supposed,  but  to 
changes  in  the  vasomotor  system.  A  tendency  to  cold  hands  and 
feet  is  another  symptom  of  this  class,  and  also  the  above-mentioned 
cardiac  pains  due,  according  to  Nothnagel,  to  an  ischemia  of  the. 
heart  muscle.  Among  the  objective  circulatory  signs  are  noted  flush- 
ing or  paling  on  psychical  disturbance,  coldness  of  the  extremities, 
dermographia,  visible  pulsation  of  the  carotids,  and  increased  ten- 
sion of  the  arterial  walls  in  the  radial  and  temporal  arteries.  Cer- 
tain forms  of  bronchial  asthma  probably  belong  to  this  class.  There 
are,  besides,  a  large  number  of  symptoms  occurring  in  combination, 
all  of  which  can  be  traced  back  to  a  nervous  irritability  of  the 
whole  circulatory  apparatus. 

The  rigidity  of  the  arterial  walls  in  nervousness  is  marked  in 
many  cases,  and  generally  all  children  with  apparently  "  thickened  " 
arteries  are  nervous.  Normally,  under  six  years,  the  pulse  only, 
and  not  the  arterial  wall,  is  felt  by  the  fingers;  and  not  until  the 
tenth  year  are  the  arterial  walls  frequently  palpable.  Pallor,  espe- 
cially in  school-children,  is  often  attributed  to  anemia,  whereas  it 
may  result  from  arterial  contraction  due  to  nervousness;  such 
children  commonly  have  dark  rings  under  the  eyes.  Marked  vaso- 
neurotic  symptoms  do  not  usually  begin  until  about  the  seventh 
year,  when  the  child  begins  to  attend  school.  As  etiological  factors 
Hamburger  attributes  an  inherited  disposition  and  certain  psychical 
and  physical  irritating  or  stimulating  influences,  such  as  fright  and 
joy  and  autosuggestion  on  the  one  hand,  and  toxins  on  the  other. 
The  prognosis  of  the  vasoneurotic  condition  is  good  if  psychical 
causes  can  be  discovered  and  avoided,  and  the  child's  disposition 
modified  by  good  hygiene  and  intelligent  mental  training. 


VASCULAR  CRISES  273 

A  number  of  the  symptoms  and  signs  which  Hamburger  describes 
are  also  met  with  in  constitutionally  hypotensive  individuals. 

The  Treatment  of  Peripheral  Spasm. — Cramps  in  the  Legs. — 
Nocturnal  cramps  in  the  legs  are  of  common  occurrence  in  hyperten- 
sive disease.  The  patient  is  often  suddenly  aroused  from  his  sleep 
by  an  intense  muscular  cramp  of  great  severity.  These  cramps, 
which  are  a  result  of  vasomotor  spasm  may  sometimes  be  relieved 
by  tightly  tying  a  string,  tape  or  handkerchief  around  the  extrem- 
ity above  the  point  of  pain,  or  by  rubbing  the  limb  vigorously  with 
stiff  brushes.  The  inhalation  of  amyl  nitrite  has  in  my  experience 
not  been  very  satisfactory,  and  immersion  of  the  extremity  in  hot 
water  is  usually  not  feasible  because  the  cramp  is  generally  over 
before  the  water  can  be  obtained.  As  a  remedy  for  chilblains, 
Raynaud's  disease  and  other  conditions  due  to  vasomotor  ataxia, 
Brunton  advises  the  use  of  the  salicylates  either  with  or  without 
the  bromides.  He  has  also  seen  good  results  follow  the  adminis- 
tration of  thyroid  extract  in  small  doses.  (See  Treatment  of 
Arterial  Hypertension,  p.  310.) 


18 


CHAPTER  XII. 

ARTERIAL  HYPERTENSIVE  CARDIOVASCULAR 
DISEASE,  NEPHRITIS,  Etc. 

Blood-pressure  variations  of  from  10  to  30  mm.  Hg.,  and 
perhaps  more,  may  be  purely  physiological  in  their  nature.  We  can 
draw  conclusions  of  the  import  of  pressure  variations  only  if  they 
exceed  these  amounts,  or  if  they  are  more  or  less  regularly  encoun- 
tered in  the  same  individual.  A  systolic  pressure  constantly  above 
160  mm.,  or  a  diastolic  pressure  cmistantly  above  100  mm.  Hg.,  is 
definitely  pathological  at  any  age.  The  younger  the  subject  with  such 
a  pressure  the  more  abnormal  must  it  be  considered.  Before  middle 
life  145  mm.  should  not  be  exceeded.  The  pathological  range  of  the 
diastolic  pressure  is  much  less  than  that  of  the  systolic. 

Arterial  sclerosis  is  often  very  variable  in  its  distribution.  As 
an  example,  the  tendency  for  syphilis  to  involve  the  ascending 
aorta  may  be  mentioned.  Extreme  degrees  of  nodular  peripheral 
sclerosis  often  occur  without  corresponding  involvement  of  the 
splanchnic  vessels,  and,  on  the  other  hand,  severe  renal  vascular 
lesions  may  be  associated  with  only  moderate  peripheral  thicken- 
ing. Palpation  of  the  radial  artery  is  therefore  not  a  procedure  by 
which  we  can  estimate  the  seriousness  of  arterial  degeneration,  nor 
is  the  absence  of  an  accentuated  aortic  sound — although  this  is 
usually  present — an  indication  that  arterial  pressure  is  not  increased. 
The  view  that  peripheral  arteriosclerosis  and  cardiac  hypertrophy 
are  secondary  to  hypertension  is  constantly  receiving  corrobora- 
tion. It  is  therefore  quite  erroneous  to  speak  of  "hardening  of  the 
arteries"  as  the  cause  of  increased  blood-pressure,  since  it  is  the 
latter  which  is  the  cause  of  the  former. 

The  height  of  the  diastolic  pressure  is  often  more  important  than 
that  of  the  systolic  tension.  The  former  is  far  less  subject  to  tem- 
porary variation  and  it  further  indicates  the  resistance  which  the 
heart  has  to  overcome.  It  is  also  more  of  an  index  of  the  mean 
pressure  than  is  the  systolic  pressure.  A  constant  diastolic  pressure 
of  or  above  100  mm.  indicates  hypertension  regardless  of  whether 
'  the  systolic  pressure  be  180  or  140  mm. 


THE  CARDIAC  OVERLOAD  IN  HYPERTENSION  275 

PLETHORA   AND   ARTERIAL   HYPERTENSION. 

Plethora,  a  term  applied  to  an  increase  in  the  total  amount  of 
the  blood,  was  formerly  supposed  to  be  a  frequent  if  not  invariable 
accompaniment  of  arterial  hypertension.  The  clinical  manifesta- 
tions of  this  condition  are  described  as  consisting  in  peripheral 
congestion  of  the  capillaries,  dilated  venules,  a  large  volume  pulse 
and  bulging  of  the  supraclavicular  fossae,  a  clinical  picture  which 
earlier  physicians  not  always  unwisely  perhaps  construed  as  an 
indication  for  phlebotomy.  Starling  states  that  the  total  blood 
volume  is  affected  not  only  by  the  oxygen  tension  of  the  respired 
air,  but  also  by  the  blood-pressure.^  Recent  experiments  have, 
however,  shown  that  changes  in  the  blood  volume  in  artificially 
induced  hypo-  or  hypertension  are  insignificant,  and  recent  studies 
in  patients  with  nephritic  hypertension  have  shown  that  the  total 
blood  volume  is  normal  if  not  actually  subnormal. ^ 

THE   CARDIAC   OVERLOAD  IN   HYPERTENSION. 

Under  normal  conditions  one  often  finds  the  systolic  pressure 
about  120,  the  diastolic  pressure  about  80,  the  pulse-pressure, 
therefore,  40.  "Thus  the  amount  of  energy  expended  in  maintain- 
ing the  circulation  in  excess  of  that  required  to  open  the  aortic 
valves  and  overcome  the  resisting  pressure  of  80,  is  40.  The  nor- 
mal load  may  therefore  be  considered  f^,  or  50  per  cent,  of  the 
diastolic  pressure"  (Stone^).  Applying  this  conception  to  hyper- 
tension it  is  apparent  that  a  systolic  and  diastolic  pressure  of  170 
and  100  mm.  respectively  yielding  a  pulse-pressure  of  70  would 
furnish  a  heart  load  of  tW  (70  per  cent.),  or  an  overload  of  20  per 
cent.  Stone's  studies  indicate  that  while  the  clinical  symptoms  of 
hypertension  generally  do  not  appear  until  the  overload  exce^eds 
25  per  cent.,  and  while  with  a  modification  of  the  habits  of  life  50 
per  cent,  may  be  borne,  yet  with  an  overload  of  50  per  cent,  myo- 
cardial exhaustion  may  be  precipitated  by  any  sudden  strain. 
Cadbury^  found  that  as  the  cardiac  load  increased,  decompensation 
became  more  frequent  in  his  series  of  305  hypertensive  cases.  With 
a  load  of  100  per  cent,  or  more,  66  per  cent,  of  the  cases  had  broken 

»  starling,  E.  G.:     Human  Physiology,  1915,  p.  857. 

^  Keith,  N.  M.,  Rowntree,  L.  G.,  and  Geraghty,  J.  T.:  A  Method  for  the  Deter- 
mination of  Plasma  and  Blood  Volume,  Arch.  Int.  Med.,  October,  1915,  p.  547. 

'  The  Clinical  Significance  of  High  and  Low  Pulse-pressures  with  Special  Refer- 
ence to  Cardiac  Load  and  Overload,  Jour.  Am.  Med.  Assn.,  1913,  Ixi,  1256. 

<  Studies  in  Blood-pressure,  Arch.  Int.  Med.,  1916,  xviii,  317. 


276     ARTERIAL  HYPERTENSIVE  CARDIOVASCULAR   DISEASE 

compensation.  I  have  not  found  the  pulse-pressure  percentage  of 
the  diastolic  pressure,  "the  cardiac  had,"  of  any  value  in  the  esti- 
mation of  circulatory  efficiency. 

THE   SIGNIFICANCE   OF   HYPERTENSION. 

Given  a  patient  with  a  well-marked  hypertension  (190  mm. 
systolic  and  110  mm.  diastolic)  we  are  de  facto  warranted  in  assum- 
ing that  the  patient  is  suffering  from  Bright's  disease,  at  least  until 
further  investigation  has  shown  that  the  hypertension  is  due  to 
some  other  cause.  Authenticated  cases,  substantiated  by  autop- 
sies are  on  record  in  which  the  kidneys  of  such  cases  have  been 
entirely  normal,  but  such  instances  are  the  exception.^  To  what 
the  rise  of  pressure  in  such  cases  is  due  has  not  been  satisfactorily 
explained,  but  arteriosclerosis  alone  without  some  renal  involve- 
ment rarely,  if  ever,  produces  hypertension.  The  absence  of  albu- 
min and  casts  does  not  necessarily  exclude  disease  of  the  kidneys; 
furthermore,  repeated  and  careful  urine  examinations  will  often 
show  characteristic  findings  in  cases  which,  on  a  few  examinations, 
may  yield  negative  results.  It  is  of  vital  importance  that  nephritic 
changes  be  discovered  early,  and  therefore  an  arterial  pressure 
disproportionately  high  in  relation  to  the  age  of  the  individual 
always  calls  for  careful  investigation,  not  only  by  means  of  the  rou- 
tine urine  examinations  but  also,  if  possible,  by  some  of  the  func- 
tional renal  tests,  preferably  phenolsulphonephthalein.  It  should 
be  remembered  that  in  the  early  stages  increased  blood-pressure 
may  be  only  intermittently  present.  The  normal  physiological 
causes  which  raise  arterial  tension  in  nephritic  cases  produce  an 
exaggerated  response.  In  the  later  stages  of  the  disease,  when  the 
cardiovascular  system  is  weakening,  the  pressure  often  falls,  but 
such  a  fall  is  generally  coincident  with  the  appearance  of  untoward 
sjnnptoms  and  physical  signs — dyspnea,  vertigo,  palpitation,  a 
diminished  urinary  output,  edema,  etc.  These  occurrences  may  also 
be  brought  about  if  a  high  pressure  be  forcibly  reduced  by  means  of 
the  nitrites;  indeed,  uremia  may  thus  be  precipitated. 

No  definite  general  rules  can  be  laid  down  for  the  prognostic 
or  therapeutic  import  of  a  fall  or  a  rise  of  blood-pressure.  The 
significance  of  such  an  event  depends  both  on  the  nature  of  the 
disease  and  on  the  state  of  the  patient.    In  patients  seriously  ill 

1  Krehl:  Ueber  die  krankhafte  Erhohung  des  arteriellen  Druckes,  Deutsch.  med. 
Wchnschr.,  1905,  xxi,  1872.  Schlayer:  Untersuchungen  ueber  d.  Funktion  kranken 
Nieren,  Deutsch.  Arch.  f.  klin.  Med.,  1911,  cii,  371. 


THE  SIGNIFICANCE  OF  HYPERTENSION  277 

a  rise  may  indicate  improvement,  whereas  the  same  finding  in  a 
case  of  arteriosclerosis  or  nephritis  may  mean  that  m-emic  mani- 
festations are  impending.  Again,  in  the  case  of  cardiovascular 
disease,  increase  of  pressure  may  indicate  better  compensation  and 
elimination  and  be  associated  with  general  improvement.  A  fall 
of  pressure,  however,  may  also  be  a  harbinger  of  good  omen  as 
indicating  a  lessening  of  toxic  products,  carbon  dioxide  accumu- 
lation, and  peripheral  vasoconstriction — the  class  of  case  which 
Sahli  has  described  as  "high-pressure  stasis."  The  fall  of  pressure 
just  alluded  to  may  be  merely  a  fall  of  the  systolic  pressure  or 
such  a  fall  associated  with  an  increase  of  the  pulse-pressure,  which, 
were  it  always  demonstrable,  would  afford  an  easily  comprehensible 
explanation  of  the  physical  improvement.  Such  is,  however,  by 
no  means  always  the  case.  Some  cases  show  marked  improvement 
coincident  with  a  decrease  of  both  maximum  and  pulse-pressure. 
Capillary  pressure,  upon  which  nutrition  depends,  does  not  vary 
directly  with  arterial  pressure,  but  is  rather  dependent  upon  the 
state  of  the  arterioles  and  the  veins.  High  pressure  is  not  neces- 
sarily associated  with  a  good,  nor  low  pressure  with  a  poor,  circula- 
tion in  the  capillaries.  If  the  arterioles  are  contracted  the  arterial 
pressure,  however  high,  fails  to  reach  the  capillaries. 

Classification  of  Arterial  Hypertension.— A  satisfactory  classifica- 
tion of  arterial  hypertension  cannot  be  made  until  our  knowledge 
of  the  etiological  factors  is  more  complete,  but  certain  types  are 
more  or  less  well  differentiated.  Arterial  hypertension  is  met  with 
in  association  with: 

1.  Demonstrable  nephritis,  as  evidenced  by  urinary  findings, 
retinal  lesions,  cardiac  hypertrophy  and  accentuation  of  the  aortic 
second  sound. 

2.  Demonstrable  arteriosclerosis  as  indicated  by  radial  thickening 
(leathery  arteries),  tortuosity  of  the  temporal  arteries,  cardiac 
hypertrophy,  retinal  arteriosclerosis  (front-piece).  Syphilis  is  the 
common  cause  of  this  type. 

3.  A  combined  type  in  which  both  renal  and  arterial  lesions  are 
manifest. 

4.  Non-nephritic  hypertension  (essential  hypertension). — Regard- 
ing this  variety  of  the  disease,  if  the  hypertension  of  polycythemia  is 
excluded,  there  is  great  difference  of  opinion. 

Some  authorities  hold  that  latent  glomerulonephritis  is  the  cause 
of  the  increased  blood-pressure;  others  maintain  that  it  is  a  distinct 
pathological  entity  due  to  some  as  yet  unknown  and  probably 
chemical  cause,  such  as  auto-intoxication  or  abnormality  of  endo- 
crine secretion. 


278    ARTERIAL  HYPERTENSIVE   CARDIOVASCULAR   DISEASE 

Riesman^  whose  classification  has  just  been  given,  emphasizes 
the  importance  of  recognizing  a  variety  of  non-nephritic  hyper- 
tension occurring  often  in  women  past  middle  life,  who  are  obese, 
undersized,  ruddy  complexioned  and  possessed  of  considerable  men- 
tal and  physical  energy,  without  demonstrable  arterial  or  renal 
abnormalities.  The  men  of  this  group  are  apt  to  be  deep-chested, 
robust  and  great  expendors  of  energy.  Obesity  is  per  se  not  infre- 
quently associated  with  arterial  hypertension.  Among  59  cases 
without  apparent  renal  or  vascular  disease,  16  showed  pressures 
between  145  and  160  mm.,  9  between  165  and  180,  and  4  between 
185  and  250  mm.  Hg.^ 

This  class  represents  a  large  and  important  group  of  hypertension 
cases  but  many  of  them  die  a  nephritic  death,  although  this  may  not 
occur  for  many  years  after  the  onset  of  the  increased  pressure. 
The  writer  is  of  the  opinion  that  many  of  these  cases  are  due  to  a 
latent  nephritis,  but  that  certainly  all  of  them  are  not.  In  the 
essential  hypertension  cases  the  blood-pressure  is  generally  lower 
in  both  its  phases  than  in  the  nephritic  group.  It  is  also  more 
amenable  to  treatment.  As  a  rule  the  dietetic  treatment  of  these 
cases  may  be  much  more  liberal  than  in  the  nephritic  group. 

The  Symptoms  of  Arterial  Hypertension. — Cardiovascular  Symp- 
toms.— Dyspnea,  palpitation,  vertigo,  oppression — often  on  going 
to  bed — cardiac  erythism,  angina  pectoris,  muscular  cramps,  spon- 
taneous or  on  exertion,  edema  of  lungs,  arrhythmia. 

Renal  Symptoms. — Polyuria,  with  nocturnal  micturition — ^the 
urine  having  a  low  specific  gravity  and  containing  a  few  hyaline 
or  granular  casts  and  a  trace  of  albumin. 

Gastro-intestinal  Symptoms. — Dyspeptic  manifestations  with  eruc- 
tations, flatulence,  postprandial  discomfort,  hyperacidity,  constipa- 
tion, epigastric  pain,  tenderness,  or  oppression. 

Nervous  Symptoms. — Matutinal  headache,^  nervousness,  restless- 
ness, irritability,  inability  to  concentrate,  easy  fatigue  from  mental 
exertion,  insomnia,  numbness,  tingling,  migraine,  transitory  aphasia, 
hemiplegia,  apoplexy. 

Ocular  Symptoms.— (a)  Spasmodic  symptoms,  without  definite 
anatomical  lesions:  amblyopia,  transient  amaurosis,  hemianopia. 

(6)  Constant  symptoms,  with  increased  pressure  of  cerebrospinal 
and  cerebro-arachnoid  fluid.    They  tend  to  be  progressive  and  may 

1  Are  We  Exaggerating  the  Dangers  of  Arterial  Hypertension,  Penn.  Med.  Jour., 
December,  1914. 

«  Faber:     Ugeskrift  f.  Laeger,  1915,  Ixxvii,  No.  23. 

'For  detailed  description  and  discussion  of  these  headaches  see  Renon,  L.:  La 
Cephalce  matinale  continue  des  Hypertendus,  Parisme  dicale,  1916,  vi,  4. 


THE  SIGNIFICANCE  OF  HYPERTENSION  279 

lead  to  subconjunctival  or  retinal  hemorrhages,  glaucoma,  etc. 
(See  page  431.) 

Aural  Symptoms. — Tinnitus  aurium,  either  with  or  without 
vertigo.    (See  page  269.) 

It  frequently  happens  that  the  subjects  of  arterial  hypertension 
complain  only  of  respiratory  or  g astro-intestinal  symptoms.  Unless 
blood-pressure  elevation  and  cardiac  hypertrophy  are  sought  for 
by  the  examiner  the  true  etiological  factor  is  apt  to  be  overlooked. 
Indigestion,  bloating  after  meals,  slight  dyspnea  on  exertion,  and 
nocturnal  micturition  are  very  suggestive  manifestations.  Such 
individuals  are  usually  overweight — overfed  and  underexercised — 
especially  in  the  case  of  men  who  have  a  plethoric,  robust  appear- 
ance. But  hypertension  also  occurs  in  abstemious  individuals,  and 
in  such  seems  to  bear  a  very  frequent  relation  to  overwork,  worry, 
and  insufficient  relaxation.  According  to  Volhard,^  the  Japanese 
are  rarely  the  subjects  of  arterial  hypertension,  a  fact  which  suggests 
that  diet  and  mode  of  life  may  account  for  their  relative  immunity. 
Severe  or  recurrent  epistaxis  is  sometimes  associated  with  and  due 
to  arterial  hypertension  and  in  such  cases  may  act  beneficially  in 
reducing  the  pressure. 

Physical  Signs. — Heart. — Hypertrophy — chiefly  left-sided,  accent- 
uation, splitting  or  reduplication  of  the  aortic  second  sound;  later, 
systolic  murmurs  at  the  mitral  or  aortic  areas  are  often  found. 
Cardiac  or  aortic  dilatation,  arrhythmia — generally  extrasystolic— 
or  when  compensation  fails,  auricular  fibrillation;  bradycardia, 
rarely  pulsus  alternans. 

Arteries. — Flushing  and  duskiness  of  the  face  and  hands;  a  hard, 
relatively  incompressible  pulse.  Cervical  pulsation,  prominent 
and  tortuous  superficial  arteries  (temporal,  brachial,  femoral), 
arterial  sounds.  Retinal  vascular  sclerosis,  rhytlimic  movements 
of  the  head  (pulsatile),  arcus  senilis. 

In  most  of  the  cases  high  blood-pressure  is  mainly  the  result 
of  vascular  spasm.  Thus,  for  example,  there  may  be  relatively 
normal  bloodvessels  with  marked  vascular  contraction;  or  distinct 
fibroid  changes  with  moderate  spasm.  Marked  lability  of  blood- 
pressure  is  common.  We  have  seen  that  in  health  pressure  varia- 
tions are  constantly  brought  about  by  diverse  influences.  In 
arterial  hypertension  all  such  responses  are  exaggerated,  and 
although  arteriolar  pressure  is  high,  capillary  pressure  is  low. 
Intercurrent  infections  generally  cause  a  temporary  fall  of  pressure. 

1  Ueber  d.  funktionelle  Unterscheidung  der  Schrumpfnieren,  Kong.  f.  inn.  Med., 
xxviii,  735. 


280     ARTERIAL  HYPERTENSIVE  CARDIOVASCULAR  DISEASE 

When  high  pressure  has  been  long  standing  one  frequently  finds  a  loss 
of  vasndar  compensation  which  results  in  a  lowering  of  pressure, 
simply  because  the  arterial  musculature  is  no  longer  able  to  maintain 
a  high  degree  of  tonicity.  The  arteries  become  relaxed,  tortuous, 
stretched,  and  are  prominent  on  inspection.  Such  a  break  in  vascular 
compensation  may  temporarily  give  relief  to  an  overburdened  heart, 
but  usually  does  so  at  the  cost  of  general  nutrition  and  sometimes 
precedes  a  progressively  downward  course  from  insufficient  renal 
activity.  Such  a  broken  cardiovascular  compensation  accounts 
for  the  secondary  fall  of  pressure  often  seen  in  the  late  stages  of 
arteriosclerosis. 

The  exact  mechanism  which  leads  to  dilatation  of  the  arteries  is  still 
uncertain.  The  transplantation  of  sections  of  a  vein  into  an  artery, 
after  the  method  of  Carrel,  does  not  lead  to  a  dilatation  of  the 
vein,  despite  the  greater  pressure  to  which  it  is,  in  its  new  situation, 
exposed;  in  fact,  a  thickening  and  decrease  in  caliber  results. 
This  fact  would  indicate  that  "increased  blood-pressure  cannot  in 
itself  produce  a  lasting  progressive  dilatation  of  the  bloodvessel."^ 

Moderate  pressures  are  naturally  better  borne  than  very  high 
ones,  and  as  a  general  rule  ambulant  patients  with  constant  pressures 
of  170  mm.  are  in  no  immediate  danger.  A  systolic  tension  of  200 
mm.  and  over,  however,  renders  sudden  catastrophies  not  unlikely, 
although  such  cardiovascular  strains  may  be  borne  for  eight  to 
ten  years  (see  p.  136). 

Arterial  hypertension  is  more  common  in  men  than  in  women, 
but  high  pressures  are  generally  better  and  longer  endured  by  the 
latter,  owing  to  their  more  ready  adaptability  to  a  restricted  life 
and  to  their  lessened  exposure  to  sudden  hypertensive  influences. 

In  some  cases  of  hypertension  marked  slowing  of  the  jmlse  is  a 
striking  clinical  feature  which,  in  the  absence  of  local  cardiac 
disease  of  the  conductive  system,  is  due  to  the  fact  that  hypertension 
stimulates  the  cardio-inhibitory  centre.  This  inhibitory  action  is 
brought  about  either  by  the  direct  effect  of  increased  pressure 
in  the  vessels  supplying  the  cardio-inhibitory  nerves,  or  reflexly 
by  stimulation  of  the  peripheral  nerves  in  the  vessels.  Increased 
pressure  in  the  left  ventricle  has  little  effect,  but  in  the  thoracic 
aorta  the  effect  is  more  marked.  This  reflex  stimulation  may 
disappear  while  the  effect  of  direct  pressure  on  the  bloodvessels 
of  the  cardio-inhibitory  centre  still  remains.^ 

»  Fischer  and  Schmieden:  Frankfurt  Ztschr.  f.  Path.,  1909,  iii,  8. 
*  Eyster  and  Hooker:  Slowing  of  the  Pulse  from  Increased  Blood-pressure,  Am. 
Jour.  Physiol.,  1908,  xxi,  373. 


NEPHRITIC  HYPERTENSION  281 


NEPHRITIC  HYPERTENSION. 


The  increased  blood-pressure  which  occurs  in  connection  with 
renal  disease,  especially  with  that  form  which  is  clinically  designated 
as  chronic  interstitial  nephritis,  is  the  most  striking  and  diagnostic- 
ally  perhaps  the  most  important  abnormality  of  arterial-  tension 
which  is  met  with  in  the  entire  domain  of  medicine.  There  seems 
to  be  a  tendency  to  revert  to  the  old  concept  of  Gull  and  Sutton, 
to  the  effect  that  chronic  interstitial  nephritis  results  from  general 
and  not  merely  local  disease  of  the  arterioles — that  it  is  primarily 
a  vascular  disease  of  which  the  renal  changes  are  but  secondary 
manifestations.  Certainly  it  is  a  fact  that  the  clinical  pictures 
as  well  as  the  blood-pressure  findings  of  chronic  interstitial  nephritis 
are  quite  different  from  those  seen  in  the  "parenchjuiatous" 
variety  of  renal  disease.  Whether  the  rise  of  blood-pressure  occurs 
before  structural  vascular  lesions  exist  is  still  in  question.  The  belief 
that  it  does  has  been  put  forth  by  von  Basch  ("angiosclerosis"), 
by  Huchard  ("presclerosis"),  and  by  AUbutt  ("hyperpiesis"). 

Hyperpiesis. — The  term  hyperpiesis  has  been  applied  to  hyper- 
tension not  due  to  demonstrable  renal,  cardiac  and  arterial  disease. 
It  is  suspected  that  if  unchecked  this  condition  may  be  an  ante- 
cedent of  organic  hypertension.  In  arteriosclerotic  conditions  the 
increased  blood-pressure,  at  least  up  to  a  certain  point,  subserves 
a  necessary  purpose;  in  hyperpiesis,  so  far  as  we  can  determine, 
the  pressure  increase  in  addition  to  being  sudden  and  associated 
with  unpleasant  sjinptoms  subserves  no  useful  function. 

Glomerulonephritis. — ^The  recent  studies  of  Volhard  and  Fahr^ 
have  emphasized  the  fact  that  blood-pressure  is  increased  in  diffuse 
glomerulonephritis  regardless  of  whether  the  condition  is  acute, 
chronic  or  in  its  terminal  stage,  whereas  simple  degenerative 
nephritis  (parenchjTnatous  nephritis) — disease  of  the  epithelial 
tubules — is  not  associated  with  hypertension.  In  the  interval 
between  the  acute  and  the  terminal  stage  of  glomerulonephritis, 
increased  blood-pressure,  together  with  slight  albuminuria  and 
occasional  casts  are  the  only  signs  of  Bright's  disease.  Other  renal 
tests  showing  normal  results. 

Simple  Renal  Sclerosis. — The  highest  blood-pressures  are  often 
met  with  in  renal  arteriosclerosis,  in  cases  in  which  the  intima  of 
the  smallest  renal  arterioles  is  thickened  and  in  which  only  occasional 
glomeruli  or  tubules  show  abnormalities.     This  condition  has  been 

1  Die  Brightische  Nierenkrankheit,  Berlin,  1914.  For  an  excellent  resum6  see 
Austin,  J.  H.,  Prog.  Med.,  1915. 


282     ARTERIAL  HYPERTENSIVE   CARDIOVASCULAR  DISEASE 

termed  simple  or  benign  sclerosis,  since  it  is  compatible  with  many 
years  of  useful  life.  This  type  of  renal  disease  corresponds  to  Gull 
and  Sutton's  primary  vascular  disease.  Its  close  connection  with 
the  heart  both  in  its  symptomatology  and  mode  of  termination 
(cardiac  failure)  has  led  Janeway  to  suggest  the  term  cardiovascular 
hypertensive  disease.  Ten  to  15  per  cent,  of  these  cases,  however, 
insidiously  develop  renal  symptoms  such  as  albuminuric  retinitis, 
decreased  phthalein  elimination,  polyuria,  or  increased  non-protein 
or  urea  nitrogen  in  the  blood.  Such  cases  clinically  and  sometimes 
histologically  represent  a  combination  form  of  the  simple  sclerotic 
and  the  glomerulonephritic  types. 

In  this  type  of  renal  disease  cardiac  hypertrophy  is  marked, 
especially  if  the  arterial  changes  in  the  kidney  begin  early  in  life. 
When  developed  later  in  life  the  frequently  associated  coronary 
sclerosis  renders  cardiac  hypertrophy  less  readily  possible.  Among 
268  cases  studied  by  Volhard  and  Fahr,  102  had  a  systolic  pressure 
above  200  mm.;  104,  between  170  and  200  mm.,  and  only  01 
pressures  below  170  mm. 


Renal  Sclerosis. 

Age,  forty  to  fifty  years. 
More  frequent  in  women. 
Apparently  well  nourished,  often  obese, 
fair  color,  not  anemic;  digestion  good. 


Blood-pressure  often  very  high. 

Retinal  lesions:  hemorrhages,  but  no 
albuminuric  retinitis. 

Phthalein  normal. 

Blood  nitrogen  normal  and  not  abnor- 
mally increased  by  protein  feeding. 
Cardiac  hypertrophy  often  marked 
with  circulatory  embarrassment, 
slowly  progressive. 

Death  generally  from  heart  failure.. 


Glomerulonephritis. 

Age,  twenty  to  fifty  years. 

More  frequent  in  men. 

Appearance:  sallow,  icteroid,  emaciated; 
tense,  prominent  vessels,  anemia, 
gastro-intestinal  disturbances,  ammo- 
niacal  odor  on  breath. 

Blood-pressure  high. 

Retinal  pictures:  hemorrhages,  albumi- 
nuric retinitis. 

Phthalein  diminished. 

Blood  nitrogen  increased,  headaches, 
vesical  disturbances,   nausea,   vomit- 


Death  often  in  uremia. 


Symptoms. — The  symptoms  of  functional  hypertension  may  be 
any  of  those  seen  in  the  organic  variety.  The  pressure  readings 
associated"  with  such  symptoms  are  characterized  by  their  lability, 
the  exacerbations  of  pressure  being  evidently  spastic  in  origin. 
Hyperpiesis  occurs  in  men  after  middle  life,  and  in  women  at  the 
time  of  the  menopause  (see  page  418).  A  disturbed  balance  between 
tlie  organs  of  internal  secretion,  especially  the  thyroid,  the  adrenals 
and  the  sexual  glands,  has  been  suggested  as  a  possible  cause. 

In.  the  vast  majority  of  cases  a  systolic  blood-pressure  of  over 
160  mm.  and  a  diastolic  pressure  of  over  100  mm.  if  constantly 


NEPHRITIC  HYPERTENSION  283 

present,  points  indubitably  to  that  symptom-fcomplex  which  is 
designated  as  interstitial  nephritis,  especially  if  it  be  associated 
with  polyuria  and  urinary  abnormalities.  It  does  not  necessarily 
mean,  of  course,  that  the  individual  in  question  will  die  of  uremia 
or  dropsy,  for  many  cases  succumb  to  cardiac  or  vascular  lesions. 
Occasionally  cases  are  encountered  in  which  practically  normal 
kidneys  are  found  at  autopsy,  but  as  a  general  rule  the  small  red 
atrophic  organ  is  found.  Many  forms  of  renal  disease  are  associated 
with  a  slightly  increased  blood-pressure,  the  notable  eiception 
being  .degenerative  (tubular)  nephritis,  amyloid  disease,  suppuratite 
pyelonephrosis,  and  tuberculosis. 

Arterial  hypertension  is  generally  a  condition  of  gradual  develop- 
ment extending  over  years  of  time,  with  a  tendency  to  increase, 
and  with  periods  of  spontaneous  intermission  or  exacerbation. 
These  latter  are  often,  but  by  no  means  always,  traceable  to  hygienic 
or  dietetic  variations.  They  are  very  closely  associated  with 
psychic  phenomena  which  are  generally  by  far  the  most  potent 
factors  for  good  or  ill. 

The  degree  of  tension  which  can  be  borne  without  subjective 
consciousness  is  mainly  an  individual  question,  but  a  pressure  of 
180  mm.  is  not  often  exceeded  without  symptoms,  and  constant 
pressures  of  200  mm.  or  over  are  generally  not  long  maintained 
before  leading  to  some  sudden  catastrophe,  such  as  angina  pectoris, 
uremia,  or  apoplexy.  The  significance  as  well  as  the  seriousness 
of  high  blood-pressure  often  receives  useful  elucidation  as  the 
result  of  an  ophthalmoscopic  examination. 

Etiology. — Volumes  have  been  written  based  upon  clinical  and 
pathological  findings,  upon  theoretical  considerations,  and  upon 
experimental  evidence  to  account  for  nephritic  hypertension  since 
1836,  when  Richard  Bright^  described  the  disease  which  now  bears 
his  name,  and  suggested  as  a  cause  of  the  cardiac  hypertrophy 
which  occurs  in  many  cases,  even  in  the  absence  of  valvular  disease: 
(1)  "That  the  altered  quality  of  the  blood  affords  irregular  and 
unwonted  stimulus  to  the  organ  immediately,"  or  (2)  "that  it 
so  affects  the  minute  and  capillary  circulation,  as  to  render  greater 
action  necessary  to  force  the  blood  through  the  distant  subdivisions 
of  the  vascular  system. "^   The  subject,  which  cannot  be  exhaustively 

•  Jores  found  that  the  absence  of  hypertrophy  in  advanced  interstitial  nephritis 
is  usual  in  the  form  known  as  the  secondary  contracted  kidney.  In  the  typical  red 
granular  kidney  hypertrophy  is  the  rule,  with,  however,  occasional  exceptions, 
Verhandl.  d.  deutsch.  path.  Gesellsch.,  1908,  xii,  187. 

'  Bright,  R. :  Cases  and  Observations  Illustrative  of  Renal  Disease  Accomi^anied 
with  the  Secretion  of  Albuminous  Urine,  Guy's  Hosp.  Repts.,  London,  183G,  i,  338. 


284    ARTERIAL  HYPERTENSIVE  CARDIOVASCULAR  DISEASE 

discussed  here,  has  recently  been  most  ably  reviewed  by  Janeway, 
from  whose  article  I  have  freely  drawn.^ 

It  is  now  generally  believed  that  the  cardiac  hypertrophy  is  in 
nearly  all  cases  due  to  arterial  hypertension,  and  to  explain  the 
cause  of  the  latter  a  number  of  hypotheses  have  been  offered. 


1— 1 

,     '^^^M 

ik 

..■■'j; 

^^ 

■'  .^   ,-,     !^  •■-'•  . 

s 

Fig.  97. 


-Photograph  of  a  cast  of  a  normal  kidney  showing  its  vascular  supply. 
(Ghoreyeb.) 


Fig.  98. — The  vascular  supply  in  slight  diffuse  nephropathy.     (Ghoreyeb.) 

I.  Mechanical  Theories. — The  old  mechanical  theory  of  Traube, 
which  attributed  the  hypertension  to  resistance  in  the  kidney  itself, 
and  which  had  almost  fallen  into  oblivion  (since  ligature  of  the 


1  Janeway,  T.  C. :     Nephritic  Hypertension,  Clinical  and  Experimental  Studies, 
Am.  Jour.  Med.  Sc,  1913,  cxlv,  625  (bibliography). 


NEPHRITIC  HYPERTENSION 


285 


renal  vessels  does  not  produce  an  increase  of  blood-pressure),  has 
recently  been  rejuvenated.  Katzenstein  has  reported  that  in  a 
dog  constriction  of  the  renal  arteries,  without  complete  obliteration, 
leads  to  an  increased  pressure.  These  results  were  not  corroborated 
by  others.    Thus  Alwens,^  by  placing  the  kidneys  in  an  oncometer 


Fig.  99. — The  vasciilar  supply  in  chronic  diffuse  nephropathy  with  atrophy. 

(Ghoreyeb.) 


Fig.  100. — Vascular  cast  of  a  tuberculous  kidney.     (Ghoreyeb.) 

without  touching  the  vessels,  on  increasing  the  pressure  2  or  3  mm. 
Hg.  above  the  arterial  tension,  found  that  blood-pressure  in  the 
aorta  rose  and  was  maintained  as  long  as  renal  compression  con- 


1  Experimentelle  Untersuchungen  u.  d.  Bedeutung  d.  mechanischen  Theorie  d. 
nephritischen  Blutdrucksteigerung,  Deutsch.  Arch.  f.  kUn.  Med.,  1909,  xcviii,  Nos. 
2  and  3. 


286    ARTERIAL   HYPERTENSIVE   CARDIOVASCULAR  DISEASE 

tinued.  But  in  these  experiments  the  flow  from  the  renal  vein 
was  diminished,  almost  suppressed,  a  fact  which  renders  the  experi- 
ment incomparable  to  nephritis,  in  which  no  such  obstruction  to 
venous  outflow  exists.  Embolization  of  the  kidney  with  paraffin, 
as  practised  by  Miiller  and  Maas,  did  not  increase  blood-pressure. 
The  blood  flowing  through  the  kidneys  under  normal  and  under 
increased  pressure  generally  shows  no  increase  in  flow,  "even  at  the 
time  when  very  pronounced  rises  in  arterial  pressure  had  developed" 
(Burton-Opitz  and  Lucas). ^ 

The  constriction  of  the  arterial  bed  which  is  associated  with  some 
forms  of  renal  disease  has  been  objectively  demonstrated  by 
Ghoreyeb's^  metallic  casts  of  the  renal  vascular  system. 

Loeb^  demonstrated  the  fact  that  the  degree  of  arterial  hyper- 
tension bore  a  more  or  less  definite  relation  to  the  degree  of  glo- 
merular renal  involvement,  and  suggested  that  the  increased  pressure 
was  a  reflex  compensatory  effort  of  the  system — an  attempt  to 
supply,  by  means  of  splanchnic  constriction,  an  adequate  blood- 
supply  which  local  vasodilatation  alone  was  no  longer  capable  of 
furnishing.  This  attractive  hypothesis  has,  however,  been  proved 
incorrect  by  Jores  and  others,  who  have  shown  that  glomerular 
changes  were  often  conspicuously  slight  when  blood-pressure  was 
highest,  and  vice  versa.  Furthermore,  as  has  been  recognized 
by  many,  and  emphasized  by  Janeway,  "amyloid  disease, 
which  is  par  excellence  a  disease  of  the  glomeruli,  in  its  pure  form 
is  almost  invariably  without  effect  on  the  blood-pressure,  and 
without  an  accompanying  hypertrophy  of  the  heart.  This  fact 
is  one  of  the  most  difficult  to  be  reconciled  with  any  theory  of 
nephritic  hypertension." 

II.  Chemical  Theories. — The  chemical  hypothesis  attributes  the 
increased  blood-pressure  to  substances  in  the  blood  as  resulting 
from  either  (1)  insufficient  renal  elimination;  (2)  disturbances  of 
internal  secretion;  (3)  toxic  substances  set  free  by  the  diseased 
kidney. 

following  the  suggestion  of  Bright,  that  an  altered  composition 
of  the  blood  might  account  for  the  cardiovascular  changes,  it  was 
for  a  time  believed  that  hypertension  was  due  to  retained  toxic 
products  which  the  kidneys  failed  to  eliminate,  which  produced  first 
spastic  hypertension  and  later  arteriolar  hypertrophy. 

>  Jour.  Exp.  Med.,  1911,  xiii,  308. 

-  Studies  on  the  Circulation,  Jour.  Med.  Research,  1916,  xxxv,  87. 
•■'  Ueber  d.  Blutdruek  u.   Herzhypertrophie  bei  Nephritikern,   Deutsch.  Arch.  f. 
klin.  Med.,  1905,  Ixxxv,  348. 


NEPHRITIC  HYPERTENSION  287 

If  after  removing  one  kidney  from  a  dog,  portions  of  the  remain- 
ing kidney  (not  exceeding  two-thirds  of  the  total  kidney  substance) 
be  resected,  the  animals  after  developing  polyuria  ultimately  die 
of  cachexia.  Five  among  eighteen  dogs  upon  whom  these  graduated 
nephrectomies  were  practised  by  Paessler  and  Heineke^  showed 
an  average  blood-pressure  increase  of  21.5  mm.,  together  with 
left  ventricular  hypertrophy.  They  found  that  after  destruction 
of  a  certain  amount  of  kidney  substance  the  quantity  of  urine 
increased,  but  was  poor  in  extractive  substances,  especially  the 
nitrogenous  elements  which  tended  to  accumulate  in  the  blood 
and  the  tissues.  The  same  phenomena  perhaps  occur  in  nephritis, 
but  they  do  not  manifest  themselves  for  a  long  time.  There  is  a 
polyuria  at  the  beginning;  later  extractive  substances  are  eliminated 
in  diminished  quantity;  finally,  nitrogen  accumulation  occurs  in 
the  blood  and  tissues,  forming  what  is  designated  as  the  products 
of  nitrogen  retention. 

Paessler  states  that  (a)  cardiac  hypertrophy  in  nephritis  is  due  to 
the  renal  disease;  (6)  as  a  result  of  the  latter  there  occurs  an 
increased  stimulability  of  the  vasoconstrictors  causing  spastic  con- 
traction of  the  arterioles;  (c)  that  right-sided  cardiac  hypertrophy 
is  secondary  to  left  ventricular  failure.  These  graduated  nephrect- 
omy experiments  leading  first  to  hypertension,  polyuria,  and  albu- 
minuria, and  later  to  gastro-intestinal  disturbances,  cachexia, 
hypotension,  and  death,  have  been  corroborated  by  Pearce^  and 
Janeway.^  The  exact  mechanism  by  virtue  of  which  this  hyper- 
tension is  produced  is  still  uncertain,  but  it  is  in  all  probability  due 
to  increased  arterial  tonus.  It  has  been  found  experimentally  that 
in  gradually  nephrectomized  animals,  arterial  spasm  is  brought 
about  by  stimuli  which  in  normal  animals  are  insufficient  to  engender 
similar  results.  It  must  be  borne  in  mind,  however,  that  "although 
the  results  of  reduction  experiments  are  striking,  the  procedures  by 
which  they  are  obtained  are  not  such  as  to  involve  only  a  single 
factor,  but  bring  several  forms  of  kidney  injury  into  play;  that  is, 
reduction  of  functional  substance  and  productive  atrophic  and 
vascular  changes,  accompanied  by  the  elimination  of  albumin  and 
casts"  (Pearce). 

1  Versuche  z.  Pathologie  d.  Morbus  Brightii,  Verhandl.  d.  deutsch.  path.  Gesellsch., 
1905,  ix,  99. 

'  The  Influences  of  the  Reduction  of  Kidney  Substance  upon  Nitrogenous  Metab- 
olism, Jour.  Exp.  Med.,  1908,  x,  632;  A  Study  of  Experimental  Reduction  of  Kidney 
Tissue  with  Special  Reference  to  the  Changes  in  that  Remaining,  ibid.,  1908,  x,  745. 

'  Note  on  the  Blood-pressure  Changes  following  Reduction  of  the  Renal  Arterial 
Circulation,  Proc.  Soc.  Exp.  Biol,  and  Med.,  1909,  vi,  109. 


288    ARTERIAL  HYPERTENSIVE  CARDIOVASCULAR  DISEASE 

Ten  cases  of  high-grade  hypertension  were  studied  at  autopsy 
by  Herxheimer.^  In  no  case  was  the  parenchyma  of  the  kidney 
microscopically  normal,  but  in  most  cases  the  changes  were  small 
in  comparison  with  the  constant  high-grade  arteriosclerotic  vascular 
degenerations,  especially  of  the  arterioles.  In  all  ten  cases  extensive 
hyaline  thickening  and  fatty  degeneration  of  the  intima  occurred. 
Slight  or  complete  obliteration  of  the  lumen  was  found.  In  some 
cases  especially  the  vasa  afferentia  of  the  glomeruli  were  involved, 
and  also  some  loops  of  the  glomeruli  showed  the  fatty  and  hyaline 
degeneration.  In  addition,  atrophy  of  the  tubules,  increase  of 
connective  tissue,  infiltration  of  round  cells  were  noted  (the  vascular 
changes  of  the  old  Gull  and  Sutton  arteriofibrosis) ;  in  the  other 
organs,  in  opposition  to  Jores's  findings,  there  were  only  occasional 
vascular  changes  (in  the  pancreas,  testicles,  liver,  and  always  much 
less  extensive  than  in  the  kidney) .  Only  in  the  spleen  were  vascular 
changes  constantly  found,  but  among  410  spleens  examined  there 
was  in  170  marked  hyaline  change  in  the  intima  of  the  small  vessels, 
even  in  young  people,  so  that  the  findings  in  the  spleen  have  no 
particular  weight. 

It  seems,  therefore,  that  although  general  arteriosclerotic  changes 
occur,  they  are  more  marked  in  the  kidneys  than  elsewhere,  and  that 
the  arterial  changes  are  the  cause,  not  the  result,  of  the  arterial  hyper- 
tension. 

Renin. — Retention  of  ordinary  metabolites,  such  as  urea,  does 
not  explain  arterial  hypertension,  and  many  attempts  have  been 
made  to  identify  pressor  substances  in  the  blood.  Tigerstedt 
and  Bergmann  succeeded  in  extracting  from  a  rabbit's  kidney  a 
substance  (renin)  which  experimentally  increased  arterial  tension 
when  injected  into  animals.  It  has  been  suggested  that  autolysis 
of  the  diseased  kidney  causes  this  substance  to  be  thrown  oft"  into 
the  general  circulation.^  Ascoli  found  that  nephrotoxic  serum 
possessed  hypertensive  properties,  while  Riva-Rocci  and  Marag- 
liano  obtained  a  similar  substance  in  increased  quantity  in  the 
diseased  kidney.  While  those  findings  have  been  widely  quoted, 
Pearce^  has  definitely  shown  that  nephrotoxins  are  not  truly  specific, 
that  "the  production  of  autonephrolysin  by  injuring  one  kidney 
was  doubtful,  and  that  Ascoli's  claim  of  a  blood-pressure-raising 
substance  could  not  be  confirmed." 

1  Niere  und  Hypertonie,  Verhandl.  d.  deutsch.  path.  Gesellsch.,  1912,  xv,  S.  211-216. 

*  Shaw,  H.  B. :  Auto-intoxication ;  its  Relation  to  Certain  Disturbances  of  Blood- 
pressure,  Goulstonian  Lectures,  Lancet,  1906,  i,  1295,  1375,  1455. 

'  The  Theory  of  Chemical  Correlation  as  Applied  to  the  Pathology  of  the  Kidney, 
Arch.  Int.  Med.,  August,  1908. 


NEPHRITIC  HYPERTENSION  289 

Pearce*  has  shown  experimentally  that  a  dog's  kidney,  unlike 
that  of  a  rabbit  and  certain  other  animals,  does  not  contain  a 
depressor  substance.  Of  course  it  does  not  follow  that  the  results  in 
human  nephritis  run  parallel  with  those  of  experimental  nephritis, 
but  a  comparison  is,  to  say  the  least,  interesting. 

Moreover,  the  injection  not  only  of  saline  kidney  extract  but 
also  that  of  other  organs  except  the  adrenal,  pituitary,  and  spleen, 
has  failed  to  increase  blood-pressure,^  and  last,  although  by  no 
means  least,  "hypertension  is  most  extreme  in  those  intensely 
chronic  types  of  nephritis  in  which  breaking  down  of  kidney  sub- 
stance must  be  at  a  minimum  if  there  is  any  at  all"  (Janeway). 

Epijiephrin. — Although  first  suggested  by  Neusser,  the  hypothesis 
that  nephritic  hypertension  is  due  to  increased  activity  of  the 
suprarenal  glands  was  prominently  brought  to  the  fore  by  Vaquez^ 
and  the  main  exponents  of  this  doctrine  are  still  to  be  found  in 
France. 

Marcuse  believes  that  as  the  result  of  the  resistance  thus  opposed 
by  the  kidneys  to  the  circulation  an  enlargement  of  the  inferior 
suprarenal  artery,  a  branch  of  the  renal  artery,  occurs.  The  supra- 
renal gland  being  thus  oversupplied  with  blood  secretes  an  increased 
quantity  of  epinephrin.  The  objection  to  this  explanation  lies 
in  the  fact  that  the  inferior  suprarenal  artery  is  often  lacking  or, 
when  present,  is  not  given  off  from  the  renal  artery. 

From  an  experimental  stand-point  it  seems  well  established  that 
there  exists  a  definite  physiological  antagonism  between  pancreas 
extract  and  adrenalin,  regarding  their  effect  on  blood-pressure  in 
normal  animals.  Zondek*  has  recently  shown  that  pancreas  extract 
exerts  its  usual  hypotensive  effects  after  the  production  of  experi- 
mental nephritis.  An  injection  of  pancreas  extract  is  capable  of 
completely  neutralizing  increased  blood-pressure  in  uranium  and 
mercurial  nephritis,  but  fails  to  do  so  in  the  case  of  chromium 
lesions. 

Cow^  has  shown  that  a  direct  vascular  connection  exists  between 
the  adrenals  and  the  kidney,  and  that  a  part  of  the  glandular  secre- 
tion passes  directly  into  the  kidney.  When  the  adrenal  vein  is 
ligated  enough  epinephrin  reaches  the  kidney  to  cause  anuria. 

1  An  Experimental  Study  of  the  Influence  of  Kidney  Extracts  and  of  the  Serum 
of  Animals  with  Renal  Lesion  on  the  Blood-pressure,  Jour.  Exp.  Med.,  1909,  xl,  430; 
The  Influence  of  Kidney  Extracts  on  Blood-pressure,  Arch.  Int.  Med.,  1912. 

2  Miller,  J.  L.,  and  E.  M.:  The  Effect  on  Blood-pressure  of  Organ  Extracts,  Joiu-. 
Physiol.,  1911,  xUii,  242. 

'  Hypertension,  Proc.  Congrfes  FranQaise  de  M6d.,  1904,  p!  338. 
*  Beeinflussung  des  Blutdrucks  d.  akuten  Experirrientellen  Nephritis  d.  Kannin- 
chens  durch  Pankreas  extrakt,  Deutsch.  Arch.  f.  klin.  Med.,  1914,  cxv,  1. 
'  Jour.  Physiol.,  1914,  xlix,  443. 
19 


290     ARTERIAL   HYPERTENSIVE   CARDIOVASCULAR   DISEASE 

Although  the  epinephrinemia  hypothesis  is  an  attractive  one, 
with  certain  facts  to  commend  it,  accumulating  evidence  points 
strongly  to  its  fallaciousness.  Thus  it  appears  (1)  that  there  is 
no  constant  relation  between  the  degree  or  even  the  presence  of 
hypertension  and  the  anatomical  structure  of  the  glands.^  (2)  The 
results  obtained  by  estimating  the  epinephrin  content  of  the  glands 
in  different  conditions  are  inconclusive.^  (3)  Most  of  the  studies 
based  upon  the  adrenalin  content  of  the  blood  are  faulty  because 
of  lack  of  controls — in  order  to  be  conclusive  the  test  should  respond 
to  a  frog's  eye,  coronary  artery,  and  intestinal  ring  method,  and, 
as  Janeway  suggests,  show  not  only  qualitatively  typical  but 
also  quantitatively  possible  epinephrin  effects.  (4)  Physiological 
evidence  indicates  that  the  adrenal  glands  are  normally  only 
intermittently  active.  They  are  emergency  organs,  but  not  con- 
stantly concerned  with  the  maintenance  of  normal  blood- pressure.^ 
All  deductions  based  clinically  or  experimentally  upon  qualitative 
or  quantitative  analysis  of  adrenalin  in  the  serum  must  be  accepted 
with  reserve.  Chemical  tests  are  out  of  the  question,  and  biologi- 
cal tests  such  as  the  frog  eye  or  muscle  strips,  are  unreliable,  since 
substances  in  the  blood  other  than  epinephrin  may  produce  the 
reaction.^  (5)  The  injection  of  epinephrin  into  the  blood  causes  an 
increased  glycemia  which,  if  sufficient  in  amount,  appears  as 
glycosuria,  and  yet  investigations  upon  patients  with  high  arterial 
tension  from  the  stand-point  of  hyperglycemia  have  shown  indefinite 
results. 

Cholesterinemia. — An  excess  of  cholestrol  in  the  blood  has  also 
been  credited  by  French  observers,  with  causing  hypertension. 
When  fed  to  rabbits  this  substance  is  said  to  cause  sclerosis  of  the 
aorta  and  adrenal  hypertrophy  associated  with  an  excess  of  lipoids 
in  the  glandular  cortex.    But  these  results  were  not  corroborated.* 

There  is  some  evidence  that  the  rise  in  blood-pressure  which  is 

'  Pearce,  R.  M.:  The  Relation  of  Lesions  of  the  Adrenal  Gland  to  Chronic 
Nephritis  and  to  Arteriosclerosis;  an  Anatomical  Study,  Jour.  Exp.  Med.,  1908,  x,  735. 
Borberg:  Das  Chroniaffine  Gewebe.  Nebennierenuntersuchunsen,  Skand.  Arch, 
f!  Phys.,  1912,  xxviii,   91.     (Abstr.  Zentralbl.  f.  d.  Ges.  inn.  Med.,   1913,  iv,  383. 

'  Ingier  and  Schmorl:  Ueber  d.  Adrenalingehalt.  d.  Nebennieren,  Deutsch.  Arch, 
f.  klin.  Med.,  1911,  civ,  262. 

'  Trendelenburg,  W. :  Ueber  d.  Beziehungen  d.  Nebennieren  z.  normalen  Blut- 
druckhohe,  Ztschr.  f.  Biol.,  1914,  xliii,  15.5.  Hoskins  and  McClure:  The  Adrenals 
and  Blood-pressure,  Arch.  Int.  Med.,  October,  1912,  p.  343. 

*  Stewart,  G.  N.:  So-called  Biological  Tests  for  Adrenalin  in  the  Blood,  with  Some 
Observations  on  Arterial  Hypertonus,  Jour.  Exp.  Med.,  1911,  xiv,  377.  O'Conner: 
Ueber  d.  Adrenalingehalt  des  Blutes,  Arch.  f.  exp.  Path.  u.  Pharmakol.,  1912,  Ixvii, 
195.     For  other  references  see  Janeway's  article,  loc.  cit. 

ii  Dixon  and  Halliburton:  Jour.  Physiol.,  1913,  xlvii,  229.  Cantieri,  C:  Rev. 
Grit,  di  Clin.  Med.,  1913,  xiv,  657. 


NEPHRITIC  HYPERTENSION  291 

met  with  in  nephritis  may  have  a  variable  and  composite  cause. 
Thus  the  injection  of  bovine  pancreas  extract  into  the  circulation 
of  rabbits  suffering  from  experimental  nephritis  produces  a  fall  of 
blood-pressure,  but  in  uranium  nephritis  larger  doses  are  required 
than  in  the  chromic  nephritides,  while  in  the  bichloride  type  of 
kidney  only  slight  pressure  changes  occur.  The  subsequent  rise  of 
pressure  also  differs  in  that  the  uranium  and  bichloride  pressures 
never  again  exceed  the  prenephritic  level,  whereas  the  chromic 
animals  promptly  rise  to  the  previous  high  level.^ 

From  what  has  preceded  it  is  sadly  evident  that  we  are  still 
unable  to  satisfactorily  explain  either  the  cause  or  the  mechanism 
of  nephritic  hypertension.  The  whole  subject  is  so  complex  and 
the  evidence  at  hand  so  contradictory  that  judgment  is  difficult. 
Janeway,  than  whom  no  one  is  better  qualified  to  speak,  draws 
the  following  conclusions: 

1.  Hypertension  may  arise  through  purely  quantitative  reduction 
of  kidney  substance  below  the  factor  of  safety.  It  is  difficult  to 
conceive  of  this  as  other  than  a  vascular  hypertonus  due  to  retained 
poisons  of  some  kind.  Its  clinical  paradigm  is  the  hypertension 
accompanying  bilateral  ureteral  obstruction  or  the  unfortunate 
surgical  removal  of  the  only  functionating  kidney.  Possibly  it  is 
one  factor  which  helps  to  produce  hypertension  in  the  contracted 
kidney. 

2.  Hypertension  may  arise  in  connection  with  the  unknown 
intoxication  which  causes  disturbances  of  the  central  nervous 
system,  and  which  we  call  uremia.  This  intoxication  is  not  one  of 
retention,  in  a  strict  sense,  although  it  is  most  commonly  present 
in  those  cases  of  advanced  nephritis  which  manifest  marked  nitrogen 
retention.  Clinically  it  is  associated  with  severe  acute  nephritis, 
sometimes  at  its  very  onset,  besides  the  subacute  and  chronic 
inflammatory  affections  of  the  kidney. 

3.  Hypertension  may  arise  in  primary  irritability  of  the  vaso- 
constricting  mechanism  from  unknown,  probably  extrarenal, 
causes  which  lead  eventually  to  arteriosclerosis.  In  this  type  the 
disease  in  the  kidney  is  the  sequence,  not  the  cause,  of  the  general- 
ized vascular  lesion.  When  it  progresses  to  a  condition  of  extreme 
atrophy,  resulting  in  the  true  primary  contracted  kidney,  a  renal 
element  may  be  added  tp  the  existing  hypertension.  In  some  cases 
arteriosclerosis  of  the  larger  vessels  may  spread  peripherally  and 
produce  a  similar  form  of  disease.     In  these  forms  of  primary 

1  Zondeck,  H. :     Die  Beeinflussung  des  Blutdrucks  d.  akuten  exper.  Nephritis  d. 
Kaninchens  durch  Pankreas  extrakt,  Deutsch.  Arch.  f.  klin.  Med.,  cxv,  Heft  1  and  2. 


292     ARTERIAL   HYPERTENSIVE   CARDIOVASCULAR   DISEASE 

vascular  disease  it  is  probable  that  eventually  widespread  narrow- 
ing of  the  arterial  stream  bed  in  some  cases  produces  a  permanent 
organic  increase  in  peripheral  resistance. 

Voegtlin  and  Macht^  have  succeeded  in  isolating  from  the 
blood  and  serum  a  crystalline  pressor  substance,  whose  pharma- 
cological action  is  different  from  epinephrin  and  from  any  other 
body  hitherto  obtained  from  the  blood.  It  produces  marked 
cardiac  stimulation  and  a  prolonged  vasoconstrictor  effect.  They 
found  that  its  physical  and  chemical  properties  seem  "to  point  to 
its  relation  to  cholesterin  on  the  one  hand  and  to  the  cortex  of  the 
adrenal  gland  on  the  other."  Gubar^  has  shown  that  the  blood-serum 
of  nephritics  has  a  pressor  effect  and  Cantieri^  found  that  there 
was  no  relation  between  high  blood-pressure  and  the  cholesterin 
content  of  the  blood.  It  is  quite  possible  that  this  new  substance 
may  prove  to  be  of  considerable  clinical  importance.  Occasionally 
hypertension  is  caused  hy  focal  infection,  such  as  pyorrhea,  sinusitis, 
chronic  tonsillitis,  suppuration  in  the  antrum,  etc.,  presumably  as 
a  result  of  toxin  absorption  and  renal  irritation.  The  relation  of 
hypertensive  cardiovascular  disease  to  syphilis  has  been  considered 
under  the  heading  of  the  latter,  p.  222. 

Renal  Circulation  and  Functionation. — Renal  function ation  is 
extremely  sensitive  to  vascular  changes  in  the  kidney.  The  kidney 
differs  from  other  organs  of  the  body  by  functionating  more  or 
less  constantly  and  by  being  frequently  forced  to  do  extra  work  by 
its  possessor.  According  to  Tiegerstedt,  from  ten  to  nineteen  times 
more  blood  passes  through  the  kidneys,  despite  their  small  size, 
than  through  all  the  other  organs  combined."*  The  kidney  normally 
contains  about  1.63  per  cent,  of  the  total  blood  (Ranke).  During 
well-marked  diuresis  it  may  contain  5.6  per  cent.^  The  anatomical 
arrangement  of  the  vessels  insures  the  longest  possible  blood  path, 
together  with  a  double  system  of  capillaries.  The  kidney  may 
show  an  increased  rate  of  blood  flow  without  an  increase  either 
in  volume  or  in  pressure,  a  fact  which  Hasebroek  uses  to  substantiate 
his  belief  in  an  active  vascular  diastole.  Renal  activity  is  inde- 
pendent of  general  systemic  pressure.*  Vasoconstriction  alone 
may  cause  a  great  reduction  of  blood  flow  in  the  kidney  (B.  Opitz). 

*  The  Isolation  of  a  New  Vasoconstrictor  Substance  from  the  Blood  and  the 
Adrenal  Cortex,  Presence  of  the  Substance  in  the  Blo'od  and  its  Action  on  the  Car- 
diovascular Apparatus,  Jour.  Am.  Med.  Assn.,  1913,  Ixi,  2136. 

=  Russk.  Vratch,  1913,  xx,  725.  » Wiener  klin.  Wchnschr.,  October  16,  1913. 

*  Lehrbuch  d.  Physiologie  des  Kreislaufes,  Leipzig,  1893,  p.  552. 

f"  Landergren  and  Tigerstedt:  Skand.  Arch.  f.  Physiol.,  1892,  iv,  242. 
« Weber:  Arch.  f.  exp.  Path.  u.  Phar.,  1905,  liv. 


NEPHRITIC  HYPERTENSION  293 

The  secretion  of  urine  varies  directly  with  the  pulse-pressure.^ 
In  fact,  a  marked  increase  of  pressure  may  produce  albuminous 
urine,  and  a  decrease  below  a  certain  point  causes  anuria. 

It  has  generally  been  believed  that  the  circulation  through  the 
kidneys,  as  regards  vascular  dilatation  or  contraction,  depended 
upon  the  amount  of  urogenous  material  in  the  blood,  and  that  the 
secretion  of  urine  increased  with  an  increased  blood-pressure  and 
blood  flow.  The  increased  pressure  is  believed  to  especially  cause 
an  excretion  of  water,  the  concentration  of  the  urine  depending 
upon  the  activity  of  the  renal  epithelium.  Hypertension  only  causes 
a  polyuria  if  the  blood  contains  a  definite  amount  of  urogenous 
material.  In  case  of  atrophied  kidneys  with  a  restricted  capillary 
area  it  is  assumed  that  an  increased  pressure  is  required  to  keep 
up  elimination.  This  view  has  had  very  wide  acceptance  from 
clinicians  who  believed  that  a  fall  of  pressure  meant  diminished 
urine  and  often  led  to  uremia,  and  who  therefore  regarded  the 
hypertension  as  compensatory  and  necessary.  Experimental  evi- 
dence, on  the  other  hand,  in  a  negative  way  indicates  that  (a) 
increased  renal  resistance  is  not  the  cause  of  hypertension ;  (6)  that 
the  latter  does  not  cause  an  increased  blood  flow  through  the 
kidneys;  (c)  that  hypertension  is  not  accountable  for  the  polyuria. 

The  results  of  experimentation,  however,  cannot  in  the  present 
state  of  our  knowledge  be  accepted  as  equivalent  to  what  occurs 
in  human  disease,  because  the  entire  problem  is  extremely  complex, 
and  because  the  syndrome  which  constitutes  chronic  interstitial 
nephritis  has  not  yet  been  produced  experimentally. 

Clinical  Phenomena. — The  rise  of  pressure  which  occurs  in  chronic 
interstitial  nephritis  is  generally  regarded  as  a  compensatory 
effect.  A  certain  amount  of  kidney  substance  has  been  destroyed, 
but  renal  elimination  must  be  maintained  at  any  cost,  and  the 
cost  is  always  a  high  one.  More  blood  must  pass  through  the 
renal  vessels  in  a  given  time,  and  this  Nature  accomplishes  by  raising 
the  blood-pressure  in  the  renal  arteries,  which  entails  an  elevation 
of  the  general  systemic  pressure.  The  latter  greatly  increases  vas- 
cular wear  and  tear  and,  when  the  heart  is  capable  of  it,  brings 
about  a  cardiac— chiefly  left  ventricular — hypertrophy. 

LawTence,^  who  has  reviewed  this  question,  finds,  however,  that 
clinical  reports  are  by  no  means  unanimous  in  declaring  hypertension 

1  Erlanger  and  Hooker:  Johns  Hopkins  Hosp.  Rep.,  1904,  xii,  145.  Hooker:  Am. 
Jour.  Physiol.,  1910,  xxxvii,  24. 

*  The  Relation  of  Hypertension  to  Urinary  Excretion,  Am.  Jour.  Med.  Sc,  Sep- 
tember, 1912,  p.  330. 


294    ARTERIAL   HYPERTENSIVE   CARDIOVASCULAR   DISEASE 

to  be  compensatory  and  protective,  and  quotes  numerous  investi- 
gators to  the  effect  that  a  lowering  of  pressure  is  coincident  with 
symptomatic  improvement.  Lawrence's  own  studies  show  that  there 
is  no  definite  relation  between  changes  in  either  the  systolic  or  the 
diastolic  pressure  j)^r  se  and  alterations  in  urinary  secretion,  but 
that  when  an  increased  p^dse-pressure  results  from  a  diastolic  fall 
the  urinary  secretion  is  augmented.  This  occurred  in  only  half 
of  the  cases  in  which  the  increased  pulse-pressure  was  due  to  a 
systolic  rise.  Thus  "  an  increase  in  the  caliber  of  the  vascular  system 
seems  to  be  more  efficient  in  promoting  diuresis  than  does  increased 
pressure  in  the  aorta  and  its  great  branches." 

It  is  the  maximum  pressure  which  is  chiefly  affected  in  nephritic 
hypertension;  the  minimum  pressure  lags  behind,  thus  affording 
a  larger  amplitude.^  In  nephritic  hypertension  both  the  minute 
volume  and  the  systolic  output  remain  practically  unchanged  (Berg- 
mann  and  Plesch);  indeed,  they  may  even  be  subnormal  in  spite 
of  the  increased  systolic  and  diastolic  pressures.  Nor  is  the  rate 
oj  flow  increased.  Even  pressures  of  200  mm.  may  be  accompanied 
by  only  a  normal  rate  of  flow,  while  a  fall  of  pressure  may  actually 
mean  an  increased  rate  (Stewart).  As  a  rule  the  blood-pressure 
increases  gradually  over  a  period  of  years,  the  individual  appearing 
in  perfect  health,  and  is  discovered  perhaps  accidentally  while  the 
patient  consults  the  physician  for  some  other  ailment,  or  it  may  be 
that  a  palpitation  of  the  heart,  fulness  of  the  head,  gastro-intestinal 
disturbances,  or  dyspnea  on  exertion  cause  him  to  seek  medical 
advice.  Hypertension  generally  manifests  itself  symptomatically 
between  fifty  and  sixty  years  of  age.  But  high  blood-pressure 
sometimes  appears  very  early  in  cases  of  acute  nephritis.  Butter- 
mann  in  one  case  observed  a  rise  of  50  mm.  within  forty-eight  hours 
of  the  onset  of  albuminuria. 

Lee^  found  renal  lesions  in  71  per  cent,  of  his  autopsied  cases 
of  hypertension,  and  of  these  in  72  per  cent,  the  lesion  was  atrophic. 
Arteriosclerosis  was  present  in  69  per  cent.,  but  in  only  1  case 
could  all  other  hypertensive  factors  be  eliminated.  Among  the 
15  cases  in  which  no  renal  disease  was  found,  7  presented  cerebral 
lesions.  No  patient  without  either  nephritis  or  arteriosclerosis  shoiced 
a  hlood-pressure  oj  over  200  mm.,  and  all  who  had  a  pressure  constantly 
or  repeatedly  above  this  figure  had  some  renal  lesion. 

Essentially  similar  results  were  observed  among  450  cases  at  the 

'  Mussor,  J.  H.,  Jr.:  The  Relation  of  High  Systolic  to  Diastolic  Pressure,  Arch. 
Diagnosis,  July,  1914. 

'Pathological  Findings  in  Hypertension,  Jour.  Am.  Med.  Assn.,  1911,  Ivii,  1179. 


NEPHRITIC  HYPERTENSION  295 

Heidelberg  clinic/  as  well  as  among  550  cases  studied  by 
Fischer.^ 

Elevation  of  blood-pressure  occurs  chiefly  in  the  atrophic  kidney 
when  the  damage  is  mainly  glomerular.  It  occurs  experimentally 
in  uranium  nephritis,  and  in  such  cases  cardiac  hypertrophy  has 
been  reported.^  It  may  occur  m  exceptional  cases  of  parench\TTiatous 
nephritis,  hydronephrosis,  etc.,  in  explanation  of  which  fact  we 
have  only  to  remember  that  the  pathological  renal  changes  are 
often  complex,  and  the  lesions  rarely  limited  exclusively  to  either 
the  epithelial  or  endothelial  structures. 

The  phenolsulphonephthalein  index  tends  to  vary  inversely  with 
the  average  systolic,  and  especially  the  diastolic  pressure,  whereas 
the  blood-urea  nitrogen  usually  varies  directly  with  the  average 
blood-pressure* 

A  high  blood-nitrogen  (70  to  120  mg.,  per  100  c.c),  is  often 
encountered  in  nephritic  hypertension,  but  in  the  primary  arterio- 
sclerotic cases  normal  readings  are  generally  found. 

The  feeding  of  protein  bears  a  direct  relation  to  the  amount 
of  nitrogen  retention  in  the  blood  of  nephritics,  especially  in  inter- 
stitial nephritis  associated  with  hypertension.  This  does  not  occur 
in  passive  congestion.  Nitrogen  retention  is  often  associated  with 
a  low  phthalein  output  and  increased  blood-pressure.^ 

The  relationship  between  the  nitrogen  content  of  the  blood  and 
the  degree  of  blood-pressure  is,  however,  not  constant,  although 
patients  with  a  high  index  are  more  subject  to  edema,  nausea, 
vomiting  and  uremia.® 

Hyperglycemia  of  a  slight  degree  was  found  by  Hopkins^  in  many 
high-pressure  nephritics,  often  in  association  with  a  low  phthalein 
output.  There  is,  however,  no  definite  relation  between  the  degree 
of  hyperglycemia  and  that  of  hypertension.  Most  of  the  cases  of 
nephritis  without  high  blood-pressure  have  a  normal  amount  of 
sugar  in  the  blood.  Venous  blood-pressure  is  not  increased  in  neph- 
ritis until  cardiac  insufficiency  begins. 

'  Schonthaler:  Bericht  ueber  in  dea  letzten  4  Jahren  an  der  Heidelberger  Medi- 
zinischen  Klinik  beobachteten  Hypertonien,  Dissertation,  Heidelberg,  1912,  p.  39. 

^  Fischer,  J. :  Relations  between  Permanently  High  Blood-pressure  and  Kidney 
Disease,  Deutsch.  Arch.  f.  klin.  Med.,  1913,  cix,  Nos.  5-6. 

'  Siegel,  W. :  Ueber  experimentale  nephritis,  Kongr.  f.  inn.  Med.,  1907,  xxiv,  217. 

*  Cadbury,  W.  W.:  Studies  in  Blood-pressure,  Arch.  Int.  Med.,  1916,  xviii,  317. 

^  Hopkins,  A.  H.,  and  Jonas  L.:  Studies  in  Renal  Functions  with  Special  Refer- 
ence to  Non-protein  Nitrogen  and  Sugar  Concentration  in  the  Blood,  Phenolsulphone- 
phthalein Elimination  and  Blood-pressure,  Arch.  Int.  Med.,  1915,  xv,  964. 

•  Seymour,  M. :  The  Effect  of  Nitrogenous  Waste  Products  in  the  Blood  in  Chronic 
Interstitial  Nephritis,  Boston  Med.  and  Surg.  Jour.,  1913,  clxix,  795. 

■  The  Concentration  of  Blood  Sugar  in  Health  and  Disease  as  Determined  by 
Bang's  Micromethod,  Am.  Jour.  Med.  Sc,  1915,  cxlix,  254. 


296    ARTERIAL  HYPERTENSIVE  CARDIOVASCULAR   DISEASE 

Sodium  Chloride  Metabolism  and  Blood-pressure. — The  elimination 
of  sodium  chloride  from  the  diet  of  dropsical  nephritics  is  sometimes 
attended  by  a  marked  increase  of  the  urinary  output.  This  sub- 
stance is  often  eliminated  with  difficulty  and  its  retention  in  the 
tissues  favors  the  retention  of  fluid.  The  effect  of  sodium  chloride 
on  blood-pressure  is  also  a  variable  one.  In  some  cases  the  institu- 
tion of  a  salt-free  diet  will  definitely  lower  blood-pressure  while 
chlorinization  will  produce  an  increase  in  pressure  perhaps  associated 
with  general  fluid  retention  and  edema  of  the  lungs. ^  Indeed  it 
has  been  claimed  that  hypotensive  properties  of  different  medicinal 
substances  owe  their  effects  directly  to  their  influence  on  the 
urinary  chloride  elimination.^  This  view  has  been  strenuously 
opposed  by  most  investigators.  Brodzki^  was  unable  to  produce 
a  rise  of  pressure  in  nephritic  cases  by  the  adtninistration  of  sodium 
chloride  or  meat  extracts.    (See  page  248.) 

Blood-pressure  and  Urinary  Secretion. — The  relation  between 
blood-pressure  and  urinary  secretion  is  complex  and  not  altogether 
understood.  It  has  been  established,  however,  that  a  certain 
minimum  as  well  as  intermittent  pressure  is  essential  to  secretion, 
but  above  the  said  minimum  pressure  the  rate  of  flow  is  much 
more  important  than  the  actual  height  of  pressure.  The  effect  of 
combined  pressure  upon  the  glomerular  structure  has  been  described 
by  J.  McCrae  as  follows: 

The  capillary  coil  which  we  call  the  glomerulus  has  a  large 
afferent  vessel  in  which  blood-pressure  is  high,  and  a  small  efferent 
vessel  in  which  it  is  low.  The  glomerulus  is  therefore  much  more 
subject  to  wear  and  tear  due  to  increased  arterial  pressure  than 
are  the  tubular  capillaries.  "The  kidney  thus  resembles  a  com- 
pound engine,  in  that  most,  if  not  all,  the  blood  goes  to  the  high- 
pressure  cylinder,  thence  much  of  it  goes  to  the  low-pressure 
tubular  capillaries,  just  as  the  stream,  deprived  of  much  of  its 
expansive  force,  goes  to  the  low-pressure  cylinder;  in  all  this  the 
mechanical  advantage  is  evident."  (J,  McCrae.)  When,  however, 
the  glomeruli  have  as  a  result  of  incessant  wear  and  tear,  undergone 
hyaline  degeneration,  the  high  pressure  is  transferred  to  the  tubules 
which  stand  this  abnormal  strain  badly,  and  may  rapidly  become 
functionally  insufficient. 

'Lowenstein:  Ueber  Beziehung  zw.  Kochsalzenthalt  u.  Blutdruck  bie  Nieren- 
kranken,  Archiv  f.  exp.  Path.,  1907,  Ivii,  137. 

'  Reneau.  A.:  Rapports  de  la  Chlorure  urinaire  avec  I'hypertension  arterielle,  etc., 
Th^.se  de  Lyon,  1909. 

'  Exper.  Untersuch.  u.  d.  Verhalten  d.  Blutdrucks  u.  d.  Einflusj  der  Nahrung  auf 
denselben  f.  chronischer  Nephritis,  Deutsch.  Arch.  f.  klin.  Med.,  May,  1908. 


NEPHRITIC  HYPERTENSION  297 

Experimentally  it  has  been  shown  that  the  amount  of  urine 
excreted  varies  directly  with  the  magnitude  of  the  pulse-pressure. 
Exceptionally  sudden  vascular  pressure  changes  have  an  augmenting 
influence.  The  chloride,  urea  and  total  nitrogen  elimination  gener- 
ally vary  with  the  pulse-pressure.  Reasoning  from  the  foregoing 
facts,  a  drug  which  will  increase  pulse-pressure  without  markedly 
lowering  the  general  blood-pressure  or  unduly  constricting  the 
renal  arterioles,  should  be  a  good  diuretic.  Digitalis  and  strophan- 
thus  fulfil  these  reiquirements  and  their  diuretic  effect  appears  to 
be  due  directly  to  their  effect  on  pulse-pressure  (Gesell).^ 

In  disease  the  relation  between  urinary  output  and  blood-pressure 
is  not  constant.  This  may  be  due  to  nervous  influence  by  virtue 
of  which  the  supply  of  renal  blood  does  not  stand  in  proportion 
to  the  general  blood-pressure.  It  cannot  be  due  to  exacerbations 
of  local  inflammation  because,  as  Herringham^  declares,  the  "ap- 
parent discrepancy  alters  from  day  to  day  in  so  inconstant  a  manner 
that  no  fresh  access  of  inflammation  can  explain  it,  and  in  the 
second  place  we  should  expect,  if  that  explanation  were  true,  that  the 
albumin  should  vary  with  the  inflammation.  A  fresh  attack  would 
probably  result  in  an  increase  of  the  albumin.  But  no  such  variation 
takes  place  constantly  in  the  albumin.  The  decrease  of  urine 
is  not  always  accompanied  by  an  increase  in  the  proportion  of 
albumin." 

As  a  general  rule,  however,  low-pressure  cases  excrete  less  lu-ine 
than  high-pressure  cases,  and  the  most  satisfactory  diuretics  do 
not  have  a  depressor  action.  The  complexity  of  the  problem  and 
the  likelihood  that  numerous  factors  have  a  variable  effect  on 
blood-pressure  is  shown  by  the  following  observations : 

"In  a  case  of  nephritis  with  albuminuria  and  persistently  high 
arterial  pressure  studied  by  Stewart^  the  pressure  was  reduced  by 
forced  breathing.  This  effect  was  in  part  due  to  an  increased 
elimination  of  carbon  dioxide  by  the  lungs  and  to  mechanical  inter- 
ference with  the  circulation.  The  administration  of  large  doses  of 
sodium  bicarbonate  was  also  associated  with  a  marked  fall  of 
pressure.  In  another  case  the  withdrawal  of  cerebrospinal  fluid 
reduced  the  arterial  pressure  apparently  by  lowering  intracranial 
pressure.  No  pressor  substance  could  be  demonstrated  in  the 
cerebrospinal  fluid." 

'  The  Relation  of  Pulse-pressure  to  Renal  Secretion,  Amer.  Jour.  Physiol.,  1913, 
xxxii,  71. 

2  Kidney  Diseases,  London,  1912,  p.  220. 

'  So-called  Biological  Tests  for  Adrenalin  in  Blood,  with  some  Observations  on 
Arterial  Hypertonus,  Jour.  Exp.  Med.,  1911,  xiv,  4. 


298    ARTERIAL   HYPERTENSIVE   CARDIOVASCULAR   DISEASE 

The  Complications  of  Hypertension. — I.  Uremia. — Chronic  uremia 
is  associated  with  high,  acute  uremia  with  very  high,  blood-pressure. 
The  latter  is  sufficiently  marked  to  be  of  great  diagnostic  value. 
The  increment  in  pressure  depends  largely  on  the  height  of  the 
preceding  average  pressure.  When  this  has  been  low,  increases  of 
100  per  cent,  are  not  unusual. 

The  cause  of  these  sudden  increments  of  tension  is  not  and 
cannot  be  known  until  the  causes  of  hypertension  in  nephritis  and 
the  nature  of  uremia  have  been  elucidated,  but  the  hypothesis  that 
many  of  the  uremic  symptoms  are  the  direct  result  of  abnormal 
local  pressure  relations  is  extremely  plausible. 

The  symptoms  of  uremia  are  well  known  and  require  no  special 
consideration.  All  of  the  transient  nervous  phenomena  described 
under  Cerebral  Vascular  Crises  (see  page  269)  may  result  from 
uremia.    Vascular  spasm  may  be  the  etiological  factor  in  either  case. 

II.  Paroxysmal  Dyspnea. — Paroxysmal  attacks  of  increased  ten- 
sion and  dyspnea  are  not  uncommon  in  arteriosclerotic  subjects, 
especially  with  renal  involvement.  It  is  quite  likely  that  these 
phenomena  are  due  to  irritation  or  disease  of  the  depressor  nerve 
in  the  aorta,  hence  they  are  encountered  especially  in  cases  of 
syphilitic  aortitis.  Bittorf^  has  reported  degeneration  of  the  depressor 
nerve  in  two  patients  with  aortic  sclerosis  (aged  forty-three  and 
fifty-six  years)  associated  with  hypertension  and  cardiac  hyper- 
trophy. 

"Having  still  more  important  bearing  on  this  subject  are  some 
old  experiments  of  Francois  Frank^  on  aortic  reflexes.  By  irritat- 
ing the  inner  surface  of  the  aorta  of  dogs  he  was  able  to  produce 
quite  constantly  certain  respiratory  phenomena.  These  consisted 
of  three  types:  (1)  Sudden  apnea  with  the  respiratory  muscles  in 
spasm  either  during  the  inspiratory  or  expiratory  phase,  or  apnea 
with  general  inhibition  of  all  respiratory  movements;  (2)  tachypnea 
without  severe  constitutional  symptoms,  and  (3)  a  slow  dyspnea 
of  severe  and  grave  form.  The  cause  of  this  dyspnea  he  showed 
quite  plainly  was  spasm  of  the  bronchial  musculature.  He  believed, 
too,  that  there  was  coincident  contraction  of  the  pulmonary  artery. 
Associated  with  this  type  of  dyspnea  was  a  contraction  of  the 
peripheral  vessels  and  rise  of  blood-pressure.  Occasionally  a  spasm 
of  the  laryngeal  muscles  occurred.  In  other  cases  he  was  able  to 
produce  all  the  signs  of  aortic  insufficiency  (the  capillary  and 
collapsing  pulse)  save  a  diastolic  murmur  through  irritation  of 
the  root  of  the  aorta  and  without  injury  to  the  sigmoid  valves. 

>  Deutsch.  med.  Wchnschr.,  1910,  No.  46. 

'  Arch,  de  Physiol.,  1890,  series  5,  ii,  508  and  547;  Jour,  de  I'anat.,  1877,  xiii,  545. 


NEPHRITIC  HYPERTENSION  299 

Stewart^  has  observed  this  last  phenomenon  and  considers  it  as  a 
reflex  from  the  root  of  the  aorta,  and  in  some  experiments  in  which 
aortic  insufficiency  was  performed  on  dogs  I  have  repeatedly 
confirmed  this  observation.  That  Frank's  respiratory  phenomena 
have  not  been  noted  since  is  almost  certainly  due  to  the  method  of 
experimentation,  for  in  Stewart's  experiment,  and  in  those  which 
others  have  performed,  full  ether  anesthesia  or  artificial  respiration 
was  employed. 

"It  is  thus  evident  that  disturbing  reflexes  may  be  set  up  experi- 
mentally in  animals  by  irritation  of  the  root  of  the  aorta,  and  there 
is  no  reason  to  suppose  that  the  same  thing  should  not  be  true  for 
man.  The  dyspnea  caused  by  bronchiospasm,  and  the  contraction 
of  the  peripheral  arteries  producing  heightened  blood-pressure  in 
the  experimental  animal  is  a  close  reproduction  of  the  paroxysmal 
dyspnea  as  it  occurs  in  syphilitic  aortitis,  and  it  seems  quite  justi- 
fiable to  suggest  that  the  two  conditions  are  the  same.  It  would 
be  difficult  to  explain  the  increase  in  blood-pressure  which  occurs 
during  these  attacks  in  man  on  the  presence  of  pain  or  of  cyanosis, 
for  pain  is  frequently  absent  and  dyspnea  may  continue  for  some 
time  (fifteen  to  thirty  minutes)  after  the  sudden  drop  in  blood- 
pressure  which  comes  with  the  relief  of  acute  symptoms.  Our 
observations  therefore  seem  to  lend  strong  support  to  the  idea 
that  these  symptoms  are  dependent  on  a  reflex  generated  at  the 
root  of  the  aorta  by  the  syphilitic  inflammatory  process."^  The 
attacks  have  been  found  to  consist  of  three  phases:  (1)  A  very 
high  systolic  and  diastolic  pressure  210-190;  (2)  falling  pressures 
in  which  the  diastolic  may  remain  disproportionately  high  (a  bad 
sign);  (3)  a  gradual  return  to  the  normal.^ 

Paroxysmal  dyspnea  may  also  occur  when  the  cerehrosyinal 
pressure  becomes  too  high.  Such  attacks  may  be  associated  with  cere- 
bral symptoms — headache,  vomiting,  vertigo,  and  with  subjective 
oppression  and  respiratory  acceleration,  but  without  preexisting 
asthmatic  s^niptoms.  It  has  been  suggested  that  although  certain 
forms  of  non-cyanotic  dyspnea  frequently  described  as  "renal" 
or  "cardiac"  are  associated  with  high  blood-pressure,  they  are 
basically  due  to  renal  defects  and  are  directly  dependent  upon  an 
acid  intoxication*    Peabody's^  studies  showed  that  when  acidosis, 

'  Archiv.  Int.  Med.,  1908,  i,  102. 

^  Longcope:  Arch.  Int.  Med.,  January,  1913. 

'  Amblard,  L.  A. :  La  Tension  Art6rielle  dans  I'oedem  aigu  du  Poumon,  Prcsso 
m6dicale,  1911,  xix,  657. 

*  Lewis,  Ryffel,  Wolf,  Cotton,  and  Barcroft:  Observations  Relating  to  Djspnea 
in  Cardiac  and  Renal  Patients,  1913,  Heart,  v,  45. 

'  The  Effect  of  Carbon  Dioxide  in  the  Inspired  Air  on  Patients  with  Cardiac 
Disease,  Arch.  Int.  Med.,  1915,  xvi,  846. 


300    ARTERIAL   HYPERTENSIVE  CARDIOVASCULAR   DISEASE 

as  indicated  by  the  alveolar  carbon  dioxide  tension,  occurs  in  cardiac 
and  cardiorenal  disease,  it  is  associated  with  an  increased  stimula- 
bility  to  carbon  dioxide  in  the  inspired  air.  In  patients  of  this  class 
dyspnea  occurs  more  readily  than  in  normal  subjects  or  in  patients 
without  acidosis.  He  was  led  to  conclude  that  while  acidosis  is 
probably  not  the  only  factor  in  cardiorenal  dyspnea  it  may  play  a 
considerable  role.  The  acidosis  of  nephritics  is  mainly  due  to  acid 
phosphates  and  not  as  in  case  of  diabetics  to  ketones.^ 

A  lowering  of  the  blood-pressure  often  brings  relief  in  attacks 
of  paroxysmal  dyspnea.  If  acidosis  is  a  factor  the  administration 
of  sodium  bicarbonate  should  be  tried. 

When  dyspnea  (asphyxia)  is  the  cause  of  the  hypertension, 
bleeding,  digitalis  and  general  measures  are  indicated.  In  the 
Cheyne-Stokes  type  of  breathing,  lumbar  puncture,  which  relieves 
cerebrospinal  pressure,  is  in  order,  although  it  has  not  much  effect 
upon  the  general  pressure.    Morphin  is  useful  in  either  type.^ 

III.  Cheyne-Stokes  Respiration. — Cheyne-Stokes  breathing  is  fre- 
quently encountered  in  association  with  arterial  hypertension. 
This  symptom  when  occurring  in  association  with  experimentally 
increased  intracranial  tension  has  been  shown  by  Gushing^  to  be 
accompanied  by  high  pressure  during  hyperpnea  and  low  pressure 
during  apnea.  The  importance  of  this  fact  from  a  clinical  stand- 
point in  order  to  differentiate  between  Cheyne-Stokes  respiration 
with  and  without  increased  intracranial  pressure  was  demonstrated 
by  Eyster;^  the  findings  of  the  latter  were  corroborated  by  Pollock,^ 
who  explains  the  exact  mechanism  of  the  symptoms  as  follows: 

"The  intracranial  tension  being  higher  than  the  general  blood- 
pressure,  cerebral  anemia  exists  and  apnea  is  present.  The  vaso- 
motor centres  are  automatically  stimulated  to  raise  the  general 
blood-pressure  in  an  effort  to  produce  an  equilibrium  between  it 
and  the  intracranial  tension.  As  the  general  blood-pressure  rises, 
respiratory  movements  recommence;  at  their  height  the  vasomotor 
centres  are  no  longer  stimulated,  the  general  blood-pressure  again 
falls,  and  the  respiratory  movements  diminish  and  finally  cease." 

Hyperpnea  is  associated  with  increased  amplitude  of  the  apex 
beat,  and  the  pulse  rate  increases  with  the  rise  of  blood-pressure. 
Arrhythmia  and  prolongation  of  the  a-c  interval  may  also  occur. 

» Howland,  J.,  and  Marriott,  W.  M.:  Jour.  Dis.  ChUd.,  1916.  xi,  309. 

*  Pal,  J. :  Paroxysmale  Hochspannungsdyspnea,  Vienna,  1907. 
'  Am.  Jour.  Med.  Sc,  1902,  cxxiv,  375;  1903,  cxxv,  1017. 

*  Johns  Hopkins  Hosp.  Bull.,  1906,  xvii,  296. 

'  Blood-pressure  in  Cheyne-Stokes  Respiration,  Arch.  Int.  Med.,  1912,  ix,  406. 


NEPHRITIC  HYPERTENSION  301 

SjTnptomatic  relief  often  follows  lumbar  puncture,  which  tem- 
porarily reduces  intracranial  tension. 

From  Eyster's  investigations  it  would  seem  that  the  stimula- 
bility  of  the  respiratory  centre  is  at  a  permanently  low  level,  which 
requires  an  abnormally  intense  stimulus  to  produce  a  response, 
the  stimulus  being  supplied  by  the  toxic  products  which  have  accu- 
mulated in  the  blood  through  apnea  and  low  pressure.  The  admin- 
istration of  CO2  toward  the  end  of  the  hyperpneic  period  has  in 
one  instance  prevented  the  recurrence  of  the  apneic  periods.^ 

IV.  Acute  Pulmonary  Edema. — Pulmonary  edema  may  occur 
in  patients  with  chronic  vascular  hypertension.  Attacks  are  pre- 
ceded by  a  rise  of  both  systolic  and  diastolic  pressures.  During 
the  attack  the  maximum  pressure,  which  has  been  very  high  (240 
to  280  mm.),  falls  greatly,  the  minimum  slightly.  At  such  times 
venesection,  although  often  beneficial,  exerts  but  little  effect  on  the 
pressure.  After  the  attack,  in  cases  which  recover,  pressure  rises 
gradually  to  the  normal.  These  symptoms,  as  was  first  shown 
by  Welch  and  Cohnheim,^  find  their  explanation  in  the  fact  that 
a  temporary  left  ventricular  failure,  while  causing  a  fall  in  the 
systemic  circulation,  produces  a  great  stasis  rise  in  the  pulmonary 
vessels  which  the  right  ventricle  is  no  longer  able  to  overcome, 
and  which  either  in  isolation  or  in  association  with  toxins  leads  to 
serious  oozing  or  vascular  rupture  into  the  pulmonary  parenchjTna. 
Experimentally,  epinephrin  may  produce  pulmonary  edema  through 
vascular  degeneration,  alveolar  inflammation,  and  increase  of 
pressure.  It  may  also  be  produced  by  clamping  the  aorta  or  com- 
pressing the  left  ventricle.  The  increased  pressure  in  the  left 
ventricle  is  transmitted  backward  to  the  pulmonary  vessels,  thus 
raising  pressure  in  the  pulmonary  artery.  This,  if  of  sufficient 
degree  tends  to  cause  a  serous  transudation  into  the  alveoli.  A 
similar  effect  may,  however,  arise  from  marked  passive  dilatation 
of  the  pulmonary  capillaries.  Heart  failure  results  when  the  gaseous 
metabolism  which  is  diminished  in  these  cases  fails  to  supply  the 
required  quota  of  contractile  energy.^  The  primary  disturbance 
therefore  seems  to  be  some  influence  on  the  nervous  system  which 
interferes  with  the  normal  regulation  of  the  correlated  vascular 
tension,  heart  action,  and  respiration  in  the  case  of  an  already 

*  Observations  on  Two  Cases  of  Cheyne-Stokes  Respiration,  Jour.  Physiol.,  1906, 
xxxiv,  6. 

«  Gesammte  Abhandl.,  Berlin,  1885,  p.  594. 

'  Matsuoka,  Y.:  Contribution  to  the  Pathology  of  Obstructive  Edema  of  the 
Lung,  Based  upon  Observations  with  the  Starling  Heart-lung  Preparation,  Jour. 
Path,  and  Bact.,  1915,  xx,  53. 


302    ARTERIAL  HYPERTENSIVE  CARDIOVASCULAR   DISEASE 

diseased  heart.^  It  has  been  suggested  that  attacks  of  pulmonary 
edema  in  nephritics  are  the  result  of  an  effort  on  the  part  of  the 
system  to  rid  itself  of  urea  and  chlorides.^  Among  405  eases  of 
pulmonary  edema  postmortem,  Coplin  found  renal  lesions  in  333. 
An  early  and  marked  fall  of  pressure  may  result  from  cardiac 
exhaustion. 

Prognosis. — Chronic  arterial  hypertension  is  a  serious  condition 
which  generally  spells  chronic  interstitial  nephritis.  The  degree 
of  hypertension  bears  no  constant  relation  to  the  severity  of  the 
nephritis  as  determined  by  the  routine  urine  examination,  the 
phthalein  elimination  or  the  amount  of  nitrogen  retention.  The 
mildest  cases  may  show  the  highest  pressures. 

The  absence  of  hypertension  in  a  case  which  presents  the  other 
clinical  evidences  of  chronic  interstitial  nephritis  suggests  the  exist- 
ence of  a  tuberculous,  syphilitic  or  amyloid  lesion  of  the  kidney. 
When  associated  with  severe  cardiac  symptoms  and  retinal  hemor- 
rhages a  lethal  termination  may  be  expected  within  a  few  years. 
The  teaching  was  formerly  current  that  nephritic  retinal  hemor- 
rhages were  invariably  followed  by  death  within  a  period  ranging 
from  six  months  to  two  years.  While  this  is  doubtless  true  in  the 
glomerulonephritic  group,  especially  if  hemorrhages  are  severe  and 
recurrent,  yet  in  individuals  of  the  arteriosclerotic  type,  particularly 
those  who  can  and  will  modify  their  manner  of  life,  there  can  be 
no  question  that  such  a  prognosis  is  unnecessarily  austere.  Many 
cases  of  retinal  hemorrhages  are  not  seen  by  the  ophthalmologist 
in  their  early  stages.  Plenty  of  cases  are  on  record  in  which  patients 
have  lived  ten  years  or  more  after  the  onset  of  nephritic  retinal 
hemorrhages.  It  is  a  common  observation  that  patients  having  a 
pressure  ranging  around  180  mm.  (systolic)  and  110  mm.  (diastolic) 
without  marked  urinary  findings,  or  of  ocular  or  cardiac  symptoms, 
may  live  for  many  years.  Strauss^  has  reported  the  case  of  a  patient 
who  lived  five  years  with  a  systolic  pressure  ranging  between  260  and 
270  mm.  Hg.  (See  page  136.)  Hypertensive  cases  are  apt  to  have 
exacerbations  of  pressure  (200  mm.  and  over)  associated  with  more 
or  less  troublesome  symptoms — insomnia,  nervousness,  irritability, 
weakness,  fatigue,  inability  to  concentrate  attention,  mental  depres- 
sion, dyspnea,  precordial  oppression,  etc. — which  will  under  appro- 

■  Amblard,  A. :  Presse  mfedicale,  August  12,  1912.  Petren:  Berl.  kliii.  Wchnschr., 
December  27,  vol.  xlvi. 

^  Lesieur,  Froment,  and  Rochaix:  Oedemes  aigus  dii  poumon.  Comparison  du 
taux  de  I'uree  et  de  chlorures  dans  le  serum  sanguin  et  dans  I'expectoration,  Soc. 
m6d.  des  Hop.,  Paris,  November  19,  1909. 

*  Deutsch.  med.  Wchnschr.,  1915,  xli,  No.  16. 


NEPHRITIC  HYPERTENSION  303 

priate  treatment  subside.  Such  cases  are  regarded  as  bad  insurance 
risks,  and  justly  so,  and  yet  with  an  intelligent  comprehension  of 
their  condition  and  a  willingness  to  curtail  the  expenditure  of 
energy,  they  may  lead  lives  of  usefulness  and  comparative  comfort 
for  many  years.  These  statements  are  borne  out  by  Paessler's^ 
graduated  nephrectomy  experiments.  The  prognosis  therefore 
often  hinges  quite  as  much  on  the  individual  as  on  the  disease. 
The  occurrence  of  well-marked  edema  in  hypertensive  cases  is  more 
serious  than  in  cases  of  valvular  disease.  The  following  rules,  as 
laid  down  by  Lichty,^  indicate  the  general  lines  upon  which  a  prog- 
nosis may  be  based: 

"  1 .  Where  hypertension  exists  with  but  little  or  no  recognizable 
disturbed  function  of  other  organs  the  outlook  is  most  favorable. 
(2)  Where  it  is  associated  with  marked  disturbance  of  any  one 
other  organ  alone  it  is  more  serious.  (3)  Where  it  is  associated  with 
great  defect  of  several  other  organs,  such  as  kidney  insufficiency, 
cardiac  insufficiency,  cirrhosis  of  the  liver,  and  lesions  of  the  gastro- 
intestinal tract,  the  prognosis  is  most  serious.  (4)  When  the  hyper- 
tension is  associated  with  symptoms  and  physical  signs  which 
disappear  after  a  more  or  less  active  and  prolonged  treatment  which, 
however,  fails  to  lower  the  tension,  a  favorable  prognosis  is  not 
unwarranted.  Such  cases  are  rather  frequent,  and  I  believe  it  is 
just  as  unreasonable  to  take  an  unfavorable  view  of  them  as  it  is 
to  predict  a  speedy  fatality  in  all  cases  of  pulmonary  tuberculosis 
where  the  bacilli  are  found  in  the  sputum.  (5)  When  the  tension 
is  found  in  connection  with  changes  in  organs  producing  such 
extreme  symptoms  as  dropsy,  ascites,  cyanosis,  and  orthopnea, 
and  when  these  symptoms  cannot  be  relieved,  whether  the  tension 
is  modified  or  not  modified  by  heroic  treatment  covering  five  to 
eight  weeks,  then  defeat  is  sure." 

As  to  the  cause  of  death  in  hypertension,  this  may  result  from 
apoplexy,  uremia,  angina  pectoris,  broken  cardiac  and  vascular 
compensation,  or  from  intercurrent  disease.  Among  565  cases  of 
renal  disease  at  St.  Bartholomew's  Hospital  209  died  from  renal 
disease  as  follows: 

Sudden  death  without  any  other  suflScient  cause 9 

From  uremia 28 

From  cerebral  hemorrhage 82 

From  cardiac  failure • 90 

209 

'  Samml.  klin.  Vortrage,  No.  408. 

*  Hypertension:  A  Report  of  Cases  under  Prolonged  Observation,  and  a  Protest 
Against  Some  Ideas,  Am.  Jour.  Med.  Sc,  May,  1913. 


304     ARTERIAL   HYPERTENSIVE  CARDIOVASCULAR   DISEASE 

The  following  tables  are  taken  from  Janeway's  article  based  on 
a  study  of  100  eases  with  a  blood-pressure  of  or  above  170  mm.  Hg. 


The  Age  of  the  Patients. 

Below  20  years '  .      .      .       2  cases,  about    2  per  cent. 

20  to  29 
30  to  39 
40  to  49 
50  to  59 
60  to  69 
70  and  over 14 


0 

" 

0 

3 

« 

"        3 

24 

« 

"      21 

39 

<( 

"      34 

32 

« 

"      28 

14 

" 

"      12 

114 

The  Duration  of  the  Illness  in  Relation  to  the  Causes  of  Death. 

Duration. 


Causes  of  death. 
Cardiac  insufficiency 
Acute  uremia 
Chronic  uremia  . 
Cerebral  apoplexy 
Angina  pectoris  . 
Acute  edema  of  lungs 


Cases. 
26 
14 
21 
14 

3 

4 


Average. 
Years.    Months. 


10 


Longest. 
Years. 

10 

8 
7 
11 
6 
4 


Shortest. 
Years.    Months. 

4 

5 

4 

11 

3  6 

1  8 


The  Immediate  Cause  of  Death. 

Gradual  cardiac  insufficiency 29 

Uremic  convulsions  or  sudden  coma 15 

Chronic  uremia 20 

Uremic  psychosis I 

Cerebral  apoplexy 14 

Acute  edema  of  the  lungs 4 

Angina  pectoris 3 

Sudden  death  (unclassified) 4 

Progressive  anemia 2 

Acute  pneumonia 4 

Unrelated  diseases 4 

100 

Stone^  has  called  attention  to  the  fact  that  the  cardiovascular 
type  of  hypertension  can  be  differentiated  from  the  nephritic,  or  as 
he  prefers  to  designate  it,  the  cerebral  type,  by  the  puhe-pressure 
and  the  cardiac  load  (see  page  275).  Thus  in  arterial  hypertension 
associated  with  valvular  or  myocardial  lesions,  the  diastolic  pressure 
is  persistently  lower  than  in  the  cerebral  type.  Hence  with  an 
equal  systolic  pressure  the  overload  is  increased — in  24  patients 
to  an  average  of  46  per  cent.  Such  a  differentiation  has  a  good 
deal  more  than  an  academic  importance  because  both  prognosis, 
therapy  and  mode  of  death  vary  very  distinctly  in  the  two  types. 


1  The  Differentiation  of  Cerebral  and  Cardiac  Types  of   Hyperarterial  Tension 
in  Vascular  Disease,  Arch.  Int.  Med.,  1915,  xvi,  775. 


NEPHRITIC  HYPERTENSION 


305 


Hypertensive  disease  as  seen  in  hospitals  presents  a  very  different 
picture  from  that  seen  in  private  practice.  In  the  former  instance 
we  see  chiefly  the  terminal  stages.  Since  the  alleviation  of  symp- 
toms as  well  as  the  prolongation  of  life  depends  mainly  upon  an 
early  recognition  of  the  condition,  it  is  important  to  know  the  early 
s\Tnptoms  from  which  patients  have  suffered.  These  are  shown 
in  the  following  table  from  Jane  way's  article.^ 


The  Relation  of  Prominent  Early  Symptoms  with  High  Blood-pressure 
TO  Causes  of  Death. 


Symptoms. 

,9 

i 

„ 

m 

a  . 

o  a 

1i 

•o   . 

S  a 

a 

"2 
'o 
a 
'Si 
a 

(A 

S 

i 

6 
•g 

1 

ii 

3  a 

2 

Si  03 

II 
■So. 

gs 

Causes  of  death. 

"o 

d 

(4 

P4 

W 

•< 

w 

PL, 

w 

> 

K 

-' 

-5 

Z 

24 

13 

1 

5 

7 

8 

1 

1 

2 

2 

1 

Gradual     cardiac     insuflB- 
ciency 

29 

7 

2 

0 

1 

0 

7 

2 

1 

2 

3 

3 

Uremic      convulsions     or 
sudden  coma 

15 

5 

1 

2 

3 

0 

11 

8 

5 

4 

5 

1 

Gradual  uremia     . 

20 

6 

2 

0 

2 

2 

2 

2 

1 

4 

0 

4 

Cerebral   apoplexy  or  its 
results 

14 

1 

1 

0 

2 

0 

0 

0 

0 

0 

0 

0 

Angina  pectoris 

3 

2 

2 

1 

1 

1 

1 

0 

0 

0 

1 

1 

Edema  of  the  lungs    . 

4 

3 

3 

0 

1 

1 

3 

2 

0 

1 

3 

6 

Other  causes    .... 

15 

48 

24 

4 

15 

11 

32 

15 

8 

13 

14 

16 

100 

It  is  evident  from  the  foregoing  tables  that  cardiovascular  failure 
is  the  commonest  cause  of  death,  while  uremia  and  apoplexy  are 
frequent,  and  angina  pectoris  is  relatively  rare.  Early  ocular 
changes  are  often  followed  by  uremic  death.  A  certain  number 
of  cases  die  as  the  result  of  a  progressive  anemia  which  has  its 
basis  in  the  renal  lesion,  and  a  small  number  from  acute  pulmonary 
edema. 

Janeway's  careful  analysis  of  cases  of  hypertensive  cardio- 
vascular disease  showed  that  the  average  duration  of  life  in  these 
cases  after  the  onset  of  hypertension  was  four  years  for  men  and 
five  for  women.  During  the  first  five  years  one-half  the  cases 
died,  one-quarter  lived  between  five  and  ten  years,  and  the  remainder 
over  ten  years.     He  further  found  that  definite  prognostic  con- 


»  A  Clinical  Study  of  Hypertensive  Cardiovascular  Disease,  Arch.  Int.  Med.,  1913, 
xii,  755. 
20 


30G     ARTERIAL   HYPERTENSIVE   CARDIOVASCULAR   DISEASE 

elusions,  based  upon  the  actual  height  of  the  pressure  found,  were 
unwarranted. 

Certain  conclusions  may  generally  be  drawn  as  to  the  ultimate 
manner  of  death  from  the  history  and  the  physical  signs.  Thus 
the  early  onset  and  predominance  of  dyspnea  or  other  symptoms 
of  cardiac  weakness  indicates  "a  more  than  50  per  cent,  probability 
of  an  eventual  death  by  cardiac  insufficiency."  The  occurrence 
of  anginoid  pain  may  be  similarly  interpreted,  although  only  one- 
third  of  these  cases  actually  die  in  a  paroxysm  of  angina  pectoris. 
In  contrast  to  these  cases  patients  with  polyuria,  especially  if 
nocturnal,  and  those  with  headaches  present  on  waking  and  gradu- 
ally disappearing,  will  in  about  50  per  cent,  of  instances  die  of 
uremia.  Progressive  or  marked  loss  of  weight  is  a  bad  symptom 
(Janeway).  A  disproportionately  high  diastolic  pressure  (120-150) 
is  more  serious  than  a  very  high  systolic  pressure,  and  appears  to 
increase  the  likelihood  of  a  uremic  or  apoplectic  death.  A  high 
systolic  pressure  with  only  a  moderate  increase  in  the  diastolic 
tension  points  toward  a  probable  death  from  cardiac  decompensation. 

Total  number  of         As  a  first 
Symptoms.  patients.  symptom  in. 

Dyspnea  (on  exertion  and  paroxysmal)  ....  20  6 

Anginoid  pain 16  6 

Edema  of  lungs 2  0 

Palpitation          13  8 

Edema  of  the  legs 8  1 

General  edema 1  1 

Polyuria 6  2 

Retention  of  urine 2  2 

Headache 12  1 

Vertigo          9  3 

Hemiplegic  attacks 5  1 

Transient  coma 1  1        . 

Uremic  convulsion 1  0 

Drowsiness 1  0 

Visual  disturbances 1  0 

Pains  (mainly  neuralgia) 8  3 

Fatigue  (physical  and  mental)      .....  6  1 

Hemorrhages 3  0 

Loss  of  flesh 2  0 

Gangrene  of  extremities 1  1 

Interriiittent  claudication 4  1 

'      Cough 1  0 

Diabetes 10  6 

Albumin  and  casts  (accidental  discovery)     ...  3  3 

Cardiac  disturbance  (accidental  discovery)         .      .  2  2 

High  blood-pressure  (accidental  discovery)         .      .  1  1 

Acute  Nephritis. — Even  in  children  acute  nephritis  often  produces 
a  marked  elevation  of  blood-pressure  which  is  of  distinct  diagnostic 


.  NEPHRITIC  HYPERTENSION  307 

value,  but  the  rise  of  pressure  does  not  always  occur.  The  pressure 
may  vary  according  as  the  glomeruli  or  tubules  are  chiefly  involved. 
In  some  cases  the  amount  of  blood  or  albumin  in  the  urine  seems  to 
bear  a  relation  to  the  height  of  the  pressure.  The  mean  average 
pressure  is  not  so  high  as  in  chronic  nephritis,  and  during  the  height 
of  some  infectious  fevers  the  blood-pressure  rise  entailed  by  the 
nephritis  may  be  more  or  less  counter-balanced  by  the  hypotensive 
effect  of  the  febrile  toxemia .  Cardiac  hypertrophy  may  be  noticeable 
in  children  and  young  adults  four  weeks  after  the  onset  of  scarlatinal 
nephritis.^  Rolleston  found  a  temporary  rise  of  pressure  in  12  out 
of  33  such  cases. 

Recent  observations  upon  several  hundred  soldiers  returned 
from  the  war  zone  on  account  of  acute  nephritis  showed  a  striking 
diurnal  variation  of  pressure  sometimes  amounting  to  GO  mm.  Hg. 
In  the  early  stages  the  pressure  changes  were  irregular,  but  later, 
morning  remissions  gave  place  to  evening  increments,  producing 
when  charted  a  "staircase"  form.  In  some  cases  a  period  of  sub- 
normal readings  were  obtained  with  a  subsequent  rise  to  the  normal. 
In  the  majority,  the  pressure  became  normal  as  albuminuria  dis- 
appeared, although  in  some  instances  the  patients  \\'ere  sent  home 
with  hypertension.  Uremia  was  generally  associated  with  high, 
sometimes  very  high  (200  mm.  Hg.)  readings.  IMarked  nocturnal 
rises  were  not  infrequently  associated  with  headache  and  par- 
oxysmal dyspnea.2 

Mercurial  Poisoning.^Poisoning  with  the  mercurial  salts  pro- 
duces renal  necrosis  associated  with  anuria.  Janeway  and  Miiller 
have  reported  cases  of  bichloride  poisoning  with  increased  blood- 
pressure  (170  mm.)  until  the  terminal  fall  occurred.^ 

Polycjrthemia. — Arterial  hypertension  occurs  in  some  cases  of 
polycythemia ;  indeed,  a  special  type  of  this  disease  is  often  alluded 
to  as  polycythemia  hypertonica.  The  fact  that  increased  blood- 
pressure  is  not  a  constant  finding  shows  that  the  origin  of  this 
symptom  cannot  lie  in  increased  hemic  viscosity,  which  is  present 
in  all  cases,  and  which  is  doubtless  often  counter-balanced  by 
reflex  vasodilatation.  Ordinary  hypertension  has  no  direct  or 
constant  relation  to  the  erythrocyte  count.* 

1  Friedlander:  Arch.  f.  Physiol.,  1881,  p.  168. 

*  Abercrombie,  R.  G. :  Systolic  Pressure  in  Acute  Nephritis,  British  Med.  Jour., 
1916,  June  23,  I,  No.  2895. 

*  Janeway,  T.  C:  Nephritic  Hypertension,  Am.  Jour.  Med.  Sc,  May,  1913,  651. 
Miiller,  F.:  Quoted  by  C.  Thorel,  Path.  d.  Kreislaufsorgane,  Ergebn.  d.  allg. 
Pathol,  u.  path.  Anat.,  1910,  xiv,  133. 

*  MoUer:  Deutsch.  med.  Wchnschr.,  October  29,  1908,  xxxiv. 


308     ARTERIAL   HYPERTENSIVE   CARDIOVASCULAR   DISEASE 

In  Lucas's^  collection  of  179  cases  the  blood-pressure  was  reported 
in  66  instances  as  follows: 

Cases. 

Blood-pressure,  145  to  170 23 

"  "         180  to  200 13 

210,  235,  240,  and  310  (one  each) 4 

220 3 

"        200 2 

"  The  blood-pressure  is  usually  above  normal  in  cases  showing  no 
splenomegaly  (Geisbock's  polycythemia  hypertonica)."  Miinzer 
suggests  that  polycythemia  may  result  from  arteriosclerotic  changes 
in  the  hemopoietic  organs,  which  reflexly  bring  about  an  increased 
blood-pressure  and  increased  functional  activity. 

That  the  increased  blood-pressure  noted  in  some  cases  is  not,  as 
is  sometimes  stated,  due  to  increased  viscosity  of  the  blood  is  shown 
by  the  following  facts:  (1)  no  definite  relation  has  been  shown  to 
exist  between  increased  viscosity  and  hypertension.  (2)  Hyper- 
tension bears  no  relation  to  the  degree  of  polycythemia  and  upon  the 
latter  the  hyperviscosity  mainly  depends.  (3)  Experiments^  have 
shown  that  increased  viscosity  tends  to  diminish  cardiac  intake 
and  hence  should,  if  it  had  any  effect,  lower  blood-pressure. 

Arterial  Hypertension  and  Hemic  Viscosity. — Martinet^  has 
studied  the  pressure-viscosity  relation  in  a  large  series  of  cases, 
and  based  upon  this  investigation  classifies  them  as  follow^s: 

1.  Eusystolic  type,  in  which  the  relation  between  maximum 
pressure  and  blood  viscosity  yields  a  quotient  close  to  4  (3.8  to 
4.5).  These  cases  even  if  the  pressure  is  abnormal  possess  no 
serious  renal  nor  cardiac  lesion. 

2.  Hypersystolic  type,  with  a  sphygmoviscometric  index  greater 
than  4.5,  an  increased  tension  with  a  lowered  viscosity.  These 
cases  have  sclerotic  kidneys,  left  ventricular  enlargement,  polyuria, 
hydruria,  and  a  tendency  to  vascular  rupture. 

3.  Hyposystolic  type,  index  less  than  3.5,  low  tension  and  high 
viscosity.  Venous  stasis:  emphysema,  tuberculosis,  mitral  lesions, 
cyanosis,  dyspnea,  enlargement  of  right  heart. 

Ue  believes  that  in  the  second  type  the  hypertension  begins 
as  an  increased  viscosity  (from  overnutrition),  which  falls  w^hen 
the  kidneys  begin  to  fail  and  the  blood  becomes  more  dilute.  He 
therefore  distinguishes  two  classes  of  hypertension: 

1  Erythremia  or  Polycythemia  with  Chronic  Cyanosis  and  Splenomegaly,  Arch. 
Int.  Med.,  1912,  x,  597. 

2  Evans,  C.  L.,  and  Ogarva,  S.:  Jour.  Physiol.,  1915,  xlix. 

spressions  art6rielles  et  viscosite  sanguine  (circulation,  nutrition,  diurese),  Paris 
(Masson),   1912. 


ARTERIAL  HYPERTENSION  309 

(a)  Simple  hypertension  (hyperviscosity). 

(6)  Cardiorena;!  hypertension  (hypoviscosity),  and  considers  that 
both  prognosis  and  treatment  are  quite  different  in  each  case. 
Thus  in  two  cases  the  iodides  increased  pressure,  dropsy,  and 
albuminuria.  Class  (b),  while  the  iodides  proved  beneficial  in  Class 
(a).  He  further  suggests  that  much  light  may  be  thrown  upon 
the  action  of  certain  drugs  (purgatives,  diuretics)  and  other  thera- 
peutic measures  (hydrotherapy,  etc.)  by  a  study  of  the  sphygmo- 
viscosity  index. 

Pellissier's^  studies  led  him  to  believe  that  in  cardiac  disease 
and  in  gestational  toxemia  a  fluctuating  blood-pressure  associated 
with  an  increased  hemic  viscosity  is  of  very  serious  import  and  in 
pregnancy  often  an  indication  for  immediate  active  treatment. 

I  Arch.  Mens.  d'Obstet.  et  de  Gyn.,  1915,  iv,  No.  5. 


CHAPTER  XIII. 
THE  TREATMENT  OF  ARTERIAL  HYPERTENSION. 

Hypertension  per  se  is  no  more  of  an  indication  for  treatment, 
except  along  preventive  lines,  than  is  the  presence  of  a  heart 
murmur.  Hypertension  is  one  of  Nature's  methods  of  compensat" 
ing  circulatory  or  visceral  deficiency,  and  in  the  carrying  out  of 
her  purpose  she  can  fortunately  not  often  be  thwarted.  Reduce 
the  pressure  in  a  case  of  Br'ght's  disease  by  violent  means,  such  as 
the  nitrites,  if  you  will.  After  a  very  brief  space  of  time  the  pressure 
will  rise  to  its  former  height.  The  direct  reduction  of  blood-pressure 
by  means  of  drugs  or  otherwise  is  a  procedure  which  should  only 
be  undertaken  after  the  most  careful  consideration  of  the  case 
from  all  its  aspects.  We  must  never  thoughtlessly  or  ruthlessly 
interfere  with  Nature's  delicately  balanced  mechanism  of  com- 
pensation. Only  in  the  face  of  impending  circulatory  failure  or 
vascular  rupture  or  temporary  pain  is  direct  treatment  indicated. 
On  the  other  hand,  in  arterial  hypertension,  as  Langdon  Brown 
has  aptly  put  it,  "the  patient  is  living  too  close  to  the  limits  of 
his  cardiac  reserve,"  and  often  a  very  high  pressure  can  be  more 
or  less  reduced  without  producing  any  deleterious  results  and 
with  marked  symptomatic  amelioration,  to  say  nothing  of  the 
saving  of  cardiovascular  wear  and  tear.  Just  how  much  pressure 
lowering  is  possible  and  desirable  must  be  determined  for  each 
individual  case,  and  in  practically  no  instance  is  such  an  effect 
to  be  sought  merely  by  the  administration  of  drugs.  Treatment 
is  generally  much  more  satisfactory  and  its  effects  more  lasting 
in  cases  showing  only  moderately  increased  pressure.  This  has 
been  well  expressed  by  Brooks,  in  saying  that  hypertension  is  not 
pathological  but  is  usually,  if  not  always,  physiological  in  import; 
that  it  tends  to  prolong  life  rather  than  to  shorten  it,  and  that 
when  its  causes  cannot  be  removed  it  should  not  be  treated  but 
maintained. 

The  reduction  of  vascular  hypertension  relieves  the  heart  of  an 
immense  amount  of  work — entirely  unnecessary  work  in  cases  in 
which  the  high  arterial  pressure  results  from  the  toxic  factors 
attendant  upon  a  faulty  mode  of  living. 


DIRECT  REDUCTION  OF  BLOOD-PRESSURE  311 

"The  heart,  beating  at  the  rate  of  70  times  a  minute,  i.  e.,  4200 
times  an  hour,  100,800  times  daily,  and  36,792,000  times  annually, 
would  pump  on  an  average  2^  ounces  of  blood  at  each  contraction, 
175  ounces  a  minute,  ^564  pounds  an  hour,  or  7|  tons  a  day," 
which  "is  equivalent  to  lifting  one  ton  122  feet  high."^ 

Since  about  10  pounds  of  blood  are  pumped  by  the  heart  per 
minute  it  is  self-evident  that  an  increase  of  pressure  ranging  between 
10  and  50  mm.,  not  to  mention  higher  figures,  must  call  for  the 
expenditure  of  an  enormous  amount  of  cardiac  work.  Further- 
more, the  heart  which  is  called  upon  to  meet  such  demands  is  often 
already  affected  by  arteriosclerotic  changes.  The  wear  and  tear 
on  the  vascular  system  is  of  course  a  no  less  important  factor. 
Dilatation  of  the  aortic  arch,  even  in  non-syphilitics  under  fifty 
years  of  age  is  of  frequent  occurrence  in  cases  of- nephritic  hyper- 
tension.^ The  entire  hydrodynamic  system  is  working  under  a 
continuous  condition  of  forced  draught.  Brunton  has  suggested 
that  hypertension  does  harm  not  only  by  interfering  with  tissue 
nutrition  but  also  by  hindering  the  vascular  supply  of  the  arteries 
themselves;  the  vasa  vasorum  being  compressed  between  the 
intima  and  the  adventitia  of  the  arterial  wall,  whereas  the  alternate 
contraction  and  expansion  which  occurs  in  health,  exercises  an 
effect  like  massage  which  favors  the  nutritional  flow. 

The  Direct  Reduction  of  Blood-pressure. — Blood-pressure  should 
very  rarely  be  directly  reduced  by  means  of  drugs  or  venesection 
except  in  case  of  emergency.  The  term  emergency  in  this  connection 
includes : 

1.  Cases  with  or  without  excessively  high  pressure  (200  mm.  -{-) 
in  which  owing  to  the  presence  of  symptoms  such  as  vertigo,  head- 
ache, numbness,  tingling,  loss  of  power,  mental  confusion  or  actual 
palsy,  an  apoplexy  is  feared.  Cases  of  aortic  aneurysm  with 
symptoms  of  imminent  suffocation.  Also  cases  of  acute  pulmonary 
edema.     Venesection  is  the  method  of  choice. 

2.  Cases  with  threatened  or  actual  angina  pectoris.  Here  the 
nitrites,  especially  nitrite  of  amyl,  are  useful. 

3.  Cases  with  high  pressures  in  which  a  cataract  extraction  is 
to  be  performed.  Sodium  nitrite  or  erythrol  tetranitrate  will  lower 
blood-pressure  and  diminish  the  risk  of  intra-ocular  hemorrhage. 

In  addition  to  the  foregoing  types,  Nicholson^  has  suggested  the 

1  Pope,  C:  Month.  Cyclop,  and  Med.  Bull.,  January,  1910. 

*  Smith,  W.  H.,  and  Kilgore,  A.  R. :     Dilatation  of  the  Arch  of  the  Aorta  in  Chronic 
Nephritis  with  Hypertension,  Am.  Jour.  Med.  Sc,  1915,  cxlix,  503. 
'  The  Clinical  Significance  of  Blood-pressure,  Med.  Record,  March  20,  1915. 


312  TREATMENT  OF  ARTERIAL  HYPERTENSION 

use  of  the  nitrites  in  hypertension  cases  about  to  be  anesthetized. 
This  would,  however,  seem  of  questionable  advisability  owing  to 
the  danger  of  increasing  "shock"  (see  page  396). 

If  general  treatment  does  not  reduce  blood-pressure  the  kidneys 
are  probably  sufficiently  sclerotifc  to  require  the  excess  of  pressure. 
A  pressure  of  200  or  over  rarely  returns  to  normal.  A  pressure 
which  has  stood  as  high  as  200  for  more  than  a  very  brief  interval 
cannot  be  expected  to  fall  much  below  160-170.  This  may  be 
considered  a  satisfactory  attainment.  Many  cases  after  carrying 
a  pressure  of  about  180  for  several  years  gradually  show  a  decline 
to  150  or  lower  owing  to  myocardial  weakening.  A  fall  below  this 
point  in  long-standing  cases  does  not  offer  a  propitious  outlook. 

There  are  often  two  factors  concerned  in  the  production  of  arterial 
hypertension:  (1)  A  basic  or  essential  factor,  the  point  to  which 
pressure  must  be  raised  to  maintain  metabolism,  and  (2)  a  super- 
added or  toxic  factor  which  results  from  faulty  habits  of  life.  It 
is  the  latter  only  which  we  are  justified  in  treating.  Ordinarily 
a  pressure  of  190  mm.  or  over  is  an  absolute  indication  for  entire 
cessation  from  work,  and  generally  rest  in  bed,  at  least  until  the 
case  has  been  carefully  studied. 

The  following  history  is  illustrative  of  what  may  be  accomplished 
in  cases  of  hypertension: 

Mr.  B.,  aged  sixty-one  years,  high-strung,  intellectual,  always  a 
hard  worker,  president  of  a  large  manufacturing  company,  presented 
himself  in  1908  complaining  of  fatigue,  nocturnal  micturition,  head- 
aches and  palpitation,  loss  of  weight,  and  anginoid  attacks.  Blood- 
pressure:  systolic,  200;  diastolic,  120  mm. 

The  arteries  were  very  sclerotic,  hard,  and  tense,  the  temporal 
vessels  prominent,  the  eyes  injected,  the  heart  enlarged  to  the  left 
with  aortic  accentuation,  a  systolic  mitral  murmur,  and  a  redupli- 
cated first  sound.     Urine:  trace  of  albumin  with  hyaline  casts. 

He  has  intelligently  cooperated  in  carrying  out  the  treatment, 
which  consisted  in  lessening  his  working  hours,  avoiding  hurry 
and  worry  as  much  as  possible,  relegating  all  unessential  work  and 
needless  telephone  calls  to  others.  Moderation  in  diet  and  rest  in 
the  recumbent  posture  late  each  afternoon.  Occasional  sweat 
baths,  with  spinal  massage. 

In  1917  he  is  comfortable,  puts  in  a  long  day's  work,  but  realizes 
his  limitations  and  submits  to  them.  He  plays  golf  actively  and 
his  pressure  ranges  between  165  and  185,  the  diastolic  element 
between  85  and  95  mm.  He  belongs  to  the  arteriosclerotic  not  the 
glomerulonephritic  group. 


DIRECT  REDUCTION  OF  BLOOD-PRESSURE  313 

He  occasionally  has  hypertensive  attacks  brought  on  by  undue 
strenuosity  which  yield  to  full  doses  of  nitrites,  purgation,  rest  in 
bed,  and  a  milk  diet,  but,  on  the  whole,  feels  vastly  better  and 
accomplishes  essentially  as  much  as  he  did  nine  years  ago. 

The  treatment  of  nephritic  hypertension  is  fraught  with  difficulties 
and  requires  the  best  of  judgment.  High  blood-pressure  leads  to 
cerebral  hemorrhage  and  cardiovascular  failure,  but  high  pressure 
is  compensating  and  necessary;  if  reduced  too  much  the  patient 
is  apt  to  suffer  from  insufficient  elimination,  which  may  lead  to 
uremia,  and  from  nutritional  failure  due  to  loss  of  capillary  pressure. 

Generally  speaking,  the  first  step  is  to  secure  rest  and  place  the 
patient  upon  a  milk  and  farinaceous  diet.  Attention  to  the  intes- 
tinal tract  is  extremely  important.  Regular  and  free  evacuation  of 
the  bowels  is  essential.  This  can  generally  be  accomplished  by  a 
judicious  regulation  of  diet,  fluid  intake,  and  exercise.  When  drugs 
are  required  liquid  petrolatum,  agar-agar,  cascara,  and  other  mild 
laxatives  are  often  useful.  The  occasional  emploj^ment  of  blue 
mass  or  calomel  followed  by  a  saline  is  often  attended  with  excellent 
results.  We  cannot  subscribe  with  enthusiasm  to  the  laudatory 
results  which  are  said  to  follow  the  use  of  the  so-called  intestinal 
antiseptics.  The  use  of  some  of  the  various  forms  of  fermented 
milk  seems  to  be  beneficial,  chiefly,  however,  if  other  forms  of 
dietary  indulgence  be  limited. 

As  has  been  pointed  out  there  are  two  main  groups  of  hyper- 
tensive cases:  (1)  Those  presenting  chiefly  cardiac  sjinptoms  and 
usually  dying  a  death  from  cardiac  decompensation.  In  these 
cases  the  systolic  pressure  is  very  high;  the  diastolic  pressure 
disproportionately  less  so.  Exercise  must  be  moderate  and  phys- 
ical overexertion  avoided.  Dietary  restriction  and  eliminative 
treatment  are  not  of  vital  importance.  When  drugs  are  required 
digitalis,  strophanthin,  ouabain,  camphor  with  or  without  carbon 
dioxide  baths  give  the  best  results.  (2)  Those  with  renal  symptoms 
who  die  with  uremic  manifestations.  In  this  group  the  diastolic 
pressure  is  disproportionately  high  (120-150).  Pressure  is  to  be 
reduced  by  mode  of  life,  diet,  purgation,  sudation,  venesection,  etc. 

Some  but  by  no  means  all  the  headaches  of  nephritis  are  due 
to  high  blood-pressure,  and  such  cases  as  are,  do  not  yield  readily 
to  therapy.  Certainly  direct  treatment  of  the  blood-pressure  is 
neither  justifiable  nor  successful,  unless  there  is  a  distinct  element 
of  toxic  vascular  spasm  which  should  be  relieved  by  purgation  or 
other  eliminative  means.  The  urgent  symptoms  of  uremia  are 
sometimes  satisfactorily  relieved  by  lumbar  yunciure  and  the  with- 
drawal of  cerebrospinal  fluid  or  by  venesection. 


314  TREATMENT  OF  ARTERIAL  HYPERTENSION 

Focal  Infections. — Renal  disease  not  infrequently  results  from, 
and  is  maintained  by,  focal  infections.  In  all  cases  of  hypertension 
careful  search  should  be  made  for  suppuration,  especially  in  the 
gums,  tonsils,  and  at  the  roots  of  the  teeth.  For  the  latter  a  com- 
petent a:-ray  examination  is  often  necessary.  The  prostate  gland, 
vermiform  appendix  and  gall-bladder  are  also  possible  sites  of 
infection. 

Purgation. — Although  drastic  purgation  has  long  been  used  for 
conditions  associated  with  marked  edema,  ascites,  and  anasarca, 
the  advisability  of  such  therapeusis  in  cases  of  cardiac  weakness 
has  been  questioned.  With  a  view  to  investigation  of  this  problem, 
Neilson  and  Hyland^  carried  out  experiments  with  the  blood- 
pressure,  etc.,  after  the  use  of  different  cathartics. 

After  two  doses  of  a  purgative  given  in  the  morning,  before 
food,  the  systolic  pressure,  which  was  chiefly  affected,  showed  an 
average  lowering  of  17  per  cent,  (the  diastolic  8  per  cent.,  the 
pulse-pressure  24  per  cent.),  while  the  pulse  rate  increased  14 
per  cent.  Symptoms  such  as  vertigo,  chilliness,  cold  extremities, 
dyspnea,  clammy  skin,  etc.,  were  observed.  Hypertensive  cases 
showed  the  most  marked  results,  and  in  these  arrhythmia  occa- 
sionally occurred. 

The  results  are  presumably  (due  to  (1)  loss  of  fluid  from  the 
blood;  (2)  unequal  distribution  of  fluid,  the  splanchnic  area  being 
chiefly  affected,  and  a  condition  comparable  to  the  experimental 
section  of  the  splanchnic  nerves  having  been  induced;  (3)  cardiac 
weakness  due  to  the  small  quantity  of  blood  which  the  heart  has 
to  handle;  increased  viscosity;  (4)  the  absorption  of  mineral  salts 
from  salines  may  have  a  direct  action  on  the  heart  or  its  nervous 
mechanism.  The  fact  that  the  pulse  rate  is  sometimes  decreased 
after  such  purgation  despite  the  lowered  blood-pressure  tends  to 
support  this  hypothesis.^ 

It  was  found  that  compound  jalaj)  powder  produced  a  more 
marked,  constant,  and  prolonged  fall  of  pressure  than  the  salines, 
a  reduction  of  5  to  15  per  cent,  being  generally  demonstrable  at 
the  end  of  twenty-four  hours. 

The  milder  laxatives  are  often  useful  in  the  reduction  of  arterial 
tension .    They  act  by  depleting  the  portal  system  and  by  removing 

*  The  Effect  of  Strong  Purging  on  Blood-pressure  and  the  Heart,  Jour.  Am.  Med. 
Assn.,  1913,  Ix,  4.36. 

^  The  intravenous  injection  of  magnesium  sulphate  in  cats  leads  to  a  sudden  fall 
of  pressure,  and  if  the  dosage  is  sufficiently  large,  to  death.  Ritter:  Ueber  d.  Einfluss 
V.  Salzlosungen  auf  den  Blutdruck,  etc.,  Deutsch.  Arch.  f.  klin.  Med.  Chir.,  1910, 
11.     See  also  McNider  and  Mathews,  Amer.  Jour.  Physiol.,  1907,  xx,  323. 


SLEEP  315 

toxic  materials  which  have  irritant  effects  on  the  vascular  walls 
and  on  the  kidneys.  The  administration  of  ten  grains  of  blue 
mass  followed  in  six  to  eight  hours  by  brisk  saline  purge  is  generally 
the  most  satisfactory  method  of  treating  the  usual  symptoms  of 
hypertension  such  as  headache,  irritability,  insomnia,  palpitation, 
etc.  Liquid  petrolatum  is  often  useful  in  producing  alimentary 
evacuation. 

Enteroclysis  is  often  beneficial  for  similar  reasons,  especially  in 
cases  of  colonic  stasis. 

Sleep. — In  many  if  not  all  cases  blood-pressure  falls  during  sleep 
(often  30  to  50  mm.)  and  is  associated  with  a  diminished  peripheral 
pulse  wave.  This  fall  of  general  arterial  pressure  is  accompanied 
by  a  sustained  and  marked  increase  in  the  volume  of  the  bra  in.  ^ 

Brooks  and  CarrolF  found  that  night  pressures  were  lower  than 
day  pressures  in  those  who  worked  by  day,  whereas  the  condition 
was  reversed  in  night  workers.  Pressure  variations  of  from  7  to 
44  mm.  were  observed.  The  least  amount  of  fall  occurred  in  those 
with  already  low  pressures.  The  maximum  fall  occurred  about 
two  hours  after  sleep  began,  the  time  at  which  insensibility  is  the 
greatest;  and  was  followed  by  a  gradual  rise  which  attained  its 
maximum  in  the  afternoon.  Getting  out  of  bed  entailed  only  a 
slight  temporary  rise  without  materially  influencing  the  regular 
cycle.  Frequent  interruption  of  sleep  tends  to  prevent  the  full 
measure  and  suddenness  of  the  primary  fall  of  tension.  If  the 
primary  drop  occurs  before  the  patient  wakes  it  does  not  recur  the 
same  night  no  matter  how  sound  the  sleep.  The  amount  of  noc- 
turnal urinary  secretion  is  apparently  independent  of  the  fall  of 
pressure.  Prolongation  of  the  sleep  interval  does  not  produce 
lower  tension.  Nocturnal  sleep,  or  even  absolute  rest,  causes  an 
average  slowing  of  the  imlse  rate  of  twenty  per  minute  as  long  as 
compensation  is  good.^ 

Some  cases  of  insomnia  show  a  reversal  of  the  normal  pressure 
relations,  i.  e.,  a  higher  pressure  by  night  than  by  day.  When 
sleep  is  produced  by  paraldehyde  the  pressure  is  reduced  to  10  mm. 
below  the  normal  individual  sleep  level.* 

The  nitrites  are  sometimes  efficient  somnifacients  in  cases  of 
arterial  hypertension,  which  is  evidence  in  favor  of  the  fact  that 
the  fall  of  pressure  is  a  factor  in  the  production  rather  than  the 

1  Shepard,  J.  F.:  The  Circulation  and  Sleep,  New  York,  1914,  p.  70. 

*  Proc.  Assn.  Am.  Phys.,  1912. 

'  Klewitz,  F.:  Der  Puis  im  Schlaf,  Deutsch.  Arch.  f.  klin.  Med.,  1913,  cxii,  38. 

^  Bruce:  Edinburgh  Medico-Chir.  Soc,  June  6,  1900,  p.  156. 


816  TREATMENT  OF  ARTERIAL  HYPERTENSION 

result  of  sleep.  Most  somnifacients  owe  their  efficacy  more  to 
general  nervous  sedation  than  to  depression  of  blood-pressure. 
The  administration  of  bromides  or  chloral  even  in  large  doses  does 
not  increase  the  fall  of  pressure  during  sleep.  Sleep  may  often  be 
induced  by  warm  baths,  moist  abdominal  compresses,  hot  mustard 
foot  baths,  or  gentle  general  massage  administered  two  hours 
after  the  evening  meal,  which  should  be  light  in  character. 

Insomnia  is  a  frequent  and  troublesome  symptom  in  hyperten- 
sive cases.  Often  it  is  the  only  symptom  of  which  the  patient 
complains.  Successful  results  can  only  be  obtained  by  a  careful 
study  of  the  individual  case,  but  as  a  general  rule  the  following 
factors  should  be  eliminated  or  avoided:  Concentrated  mental 
work  or  strenuous  physical  exercise  during  the  evening.  Excite- 
ment of  any  kind  whether  by  playing  "Bridge,"  or  otherwise. 
Excessive  smoking  or  any  coffee  drinking  after  dinner.  If  strychnin 
or  nux  vomica  is  administered  for  therapeutic  reasons  the  evening 
doses  must  be  omitted.  Business  worries  and  household  cares 
must  be  laid  aside. 

Rest.^ — Rest  in  bed  for  a  week,  with  a  milk  diet  is  often  the  best 
remedy  for  reducing  blood-pressure.  It  is  likely  that  the  mental 
relaxation  thus  brought  about  is  more  important  than  the  physical 
repose.  Gumprecht  called  attention  to  the  fall  of  pressure  observed 
in  laborers  on  entering  the  hospital,  a  result  which  he  attributed  to 
the  unwonted  rest.  But  it  is  also  a  fact  that  patients  who  take 
their  worries  and  anxieties  to  bed  with  them  show  less  improve- 
ment than  do  those  who  submit  to  the  ordeal  and  succeed  for  the 
time  being  in  throwing  all  responsibilities  overboard,  leaving  their 
intellectual  realm  bordering  on  a  temporary  nirvana.  This  is  also 
strikingly  exemplified  by  the  patient  whose  symptoms  all  disappear 
the  minute  he  leaves  home  for  a  vacation. 

Exercise.^ — In  ambulant  cases  of  chronic  arterial  hypertension 
with  good  compensation  the  milder  forms  of  exercise  are  of  great 
benefit.  Walking  or  golf  are  to  be  recommended,  but  with  the 
warning  that  such  exercise  must  be  deliberate  and  that  sudden, 
violent,  or  too  prolonged  efforts  are  harmful.  The  beneficial  effects 
are  attributable  to  a  greater  distribution  of  blood  to  the  periphery, 
sudation,  improved  digestion  and  metabolism,  as  well  as  to  the 
distraction  and  psychic  relaxation  thus  induced.  Severe  or  sudden 
exercise  such  as  heavy  lifting,  running  or  stooping  must  be  avoided. 
Patients  should  be  cautioned  against  straining  at  stool.  The 
writer  has  seen  disastrous  retinal  hemorrhages  result  from  lack  of 
this  precaution.     Severe  physical  exertion  in  man  may  raise  the 


DTET  317 

blood-pressure  from  110  to  180  mm.,  chiefly  owing  to  the  rise  of 
intra-abdominal  and  intrathoracic  pressure/  and  it  is  more  than 
likely  that  where  hypertension  exists,  even  greater  increments  of 
pressure  may  occur. 

Diet. — Overeating. — The  eating  of  food  which  has  not  been 
earned  by  physical  exercise,  is  one  of  the  chief  causes  of  arterial 
hypertension;  hence  the  regulation  of  diet  plays  an  important 
part  in  treatment.  The  main  indications  are  to  restrict  proteid 
food,  especially  meats;  salt  and  substances  capable  of  causing 
renal  irritation  (condiments,  alcohol)  or  digestive  disturbance. 
The  diet  should  be  largely  lactovegetarian,  and  limited  in  quantity 
so  as  to  just  supply  the  nutrient  and  caloric  requirements.  It  is 
surprising  on  how  small  a  ration  metabolic  equilibrium  can  be 
maintained  in  people  past  middle  life.  A  high  protein  ration, 
it  is  true,  even  with  an  increased  amount  of  non-protein  nitrogen 
in  the  blood,  does  not  appear  to  directly  influence  blood-pressure, 
but  there  are  certain  types  of  nephritis  in  which  it  is  harmful  and 
certainly  it  must  throw  additional  work  on  the  kidneys.^  Tyrosin, 
an  amino-acid,  formed  in  the  digestion  of  meat,  may  be  converted 
by  the  activity  of  the  Bacillus  aminophylus  intestinalis  into  tyramin. 
The  latter  substance  possesses  high  grade  vasoconstrictor  properties. 
Prolonged  fasting  produces  a  gradual  fall  of  blood-pressure  which  in 
Charteris's  case  amounted  to  25  per  cent,  of  the  normal  reading. 
The  pressure  returns  rapidly  to  the  normal  after  the  resumption 
of  food. 

In  the  case  studied  by  Higgins  in  Benedict's^  Laboratory,  the 
general  trend  of  both  the  systolic  and  the  diastolic  curves  in  both 
the  sitting  and  in  the  prone  posture  was  to  decrease  during  the  first 
fifteen  days  of  the  fast,  systolic  134  to  94,  diastolic  100  to  72  mm. 
Ilg.  This  was  followed  by  either  a  constant  value  or  a  slight 
tendency  to  rise  during  the  last  part  of  the  fast. 

The  decline  of  the  blood-pressure  i's  apparently  due  to:  (1)  a 
decreased  contractibility  of  the  heart  muscle,  and  (2)  decreased 
vasomotor  tone.  The  heart  becomes  smaller  during  the  fast.  Three 
days  after  the  end  of  the  fast,  pressure  was  again  normal. 

Thorough  mastication  and  slow  eating  are  essential.  Neither 
mental  nor  physical  exertion  should  be  allowed  immediately  after 

1  McCurdy,  J.  H.:  The  Effect  of  Maximum  Muscular  Effect  on  Blood-pressure, 
Am.  Jour.  Physiol.,  1901,  v,  98. 

*  Frothingham  and  Smillie:  "Different  Nitrogenous  Diets  in  Nephritie,"  Arch. 
Int.  Med.,  1915,  xv.  No.  2. 

'  Study  of  Prolonged  Fasting,  Pub.  Carnegie  Inst,  of  Washington,  1915, 
p.  119. 


318  TREATMENT  OF  ARTERIAL  HYPERTENSION 

food.  Rest  before  eating  often  materially  assists  the  subsequent 
digestion.^ 

Blood-pressure  rises  after  the  ingestion  of  food,  probably  as  the 
result  of  gastric  distention;  this  is  followed  by  hypotension,  which 
corresponds  to  the  time  of  attive  gastric  secretion,  and  finally 
there  occurs  a  second  rise  which  is  probably  due  to  intestinal 
distention  and  plethora,  and  which  is  proportional  to  these  factors. 
It  is  evident,  therefore,  that  large,  bulky,  stimulating  meals  should 
be  avoided  in  arterial  hypertension. 

In  an  uncooked  state  certain  foods  may  exert  a  direct  effect 
upon  blood-pressure,  perhaps  due  to  their  effect  on  the  thyroid 
gland.  Liver  substance  fed  to  rabbits  causes  a  50  per  cent,  increase 
in  pressure,  and,  according  to  Lubarsch,  vascular  lesions;  while 
the  administration  of  taurocholate  or  glycocholate  of  sodium 
causes  a  fall.^ 

The  question  as  to  whether  cardiac  symptoms  result  from  purely 
mechanical  disturbances,  such  as  alterations  in  blood-pressure, 
upward  displacement  of  the  diaphragm  or  the  heart,  or  from  reflex 
action  on  the  part  of  the  vagus,  receives  some  elucidation  from 
recent  experiments. 

The  abdomen  is  encircled  by  an  inelastic  bandage,  and  pressure 
(110  mm.  Hg.)  is  exerted  upon  it  by  the  inflation  of  a  large  rubber 
bag,  observations  on  blood-pressure,  together  with  radiographic 
studies  of  the  diaphragm,  being  made.  In  health  such  a  procedure 
produces  a  slight  increase  in  the  pulse  and  respiratory  rate  with  a 
trifling  fall  of  blood-pressure.  In  cardiopaths  occasionally  marked 
fluctuations  of  blood-pressure  occur,  but  usually  the  results  are 
closely  akin  to  those  produced  in  healthy  people,  showing  that 
mere  elevation  of  the  diaphragm  is  of  but  little  importance.  Infla- 
tion of  the  stomach  with  air  causes  a  slight  fall,  and  with  carbon 
dioxide,  a  rise  of  the  diaphragm,  chiefly  on  the  left  side.  In  health 
a  slight  rise  of  blood-pressure  results  from  this  procedure,  in  cardio- 
paths— especially  in  mitral  disease — a  marked  fall  of  pressure  (20 
mm.)  occurs  in  about  half  of  the  cases,  a  fall  which  bears  no  relation 
to  diaphragmatic  displacement.^ 

It  would  seem,  therefore,  that  gastric  disturbances  cause  cardiac 

1  The  question  of  diet  has  been  reviewed  and  ably  discussed  by  Hecht :  Ueber  d. 
diatetische  Beeinflussung  pathologischer  Blutdruckst«igerung,  Ztschr.  f.  klin.  Med., 
1912,  Ixxvi,  87. 

2  Van  Leersum,  E.  C. :  Alimentare  Blutdruckerhohung,  Ztschr.  f .  exp.  Path.  u. 
Ther.,   1912,  xi,  408. 

'  Funder:  Ueber  d.  Einfluss  intraabdominaler  Druckst«igerung  u.  des  Fiilluugszu- 
standes  des  Magens  auf  d.  Blutdruck,  Deutsch.  med.  Wchnschr.,  1913,  xxxix,  646. 


CONSERVATION  OF  ENERGY  319 

embarrassment  chiefly  through  reflex  and  only  secondarily  through 
direct  mechanical  causes  (see  Tympanites,  page  268). 

The  main  dietary  rule  is  moderation.  Meat  in  quantities  up  to 
100  or  150  gm.  a  day  may  generally  be  allowed.  The  prejudice 
against  red  meat  and  eggs  is  unfounded.  There  is  chemically  but 
little  difference  between  red  and  white  meats.  If  the  amount  be 
within  the  allowable  limit  it  makes  but  little  difference  which  the 
patient  takes  (see  Nitrogen  Retention,  page  295) .  It  is  often  neces- 
sary to  restrict  the  use  of  sodium  chloride,  especially  if  the  patient 
is  edematous;  for  while  there  is  no  invariable  absolute  parallelism 
between  salt  retention  and  blood-pressure,  the  ingestion  of  salt  in 
quantities  greater  than  is  demanded  for  physiological  equilibrium 
places  unnecessary  work  on  the  kidneys.  An  absolutely  salt-free 
diet  is  difficult  to  secure  and  excessively  irksome  to  the  patient, 
while  the  benefits  derived  from  the  same  do  not  justify  its  adoption. 
Recent  experiments  indicate  that  the  average  individual  consumes 
much  more  salt  than  is  necessary  for  physiological  •  equilibrium. 
This  combined  with  the  use  of  condiments  leads  to  greater  con- 
sumption of  both  food  and  fluid  than  is  required  for  nutrition,  and 
thus  throws  an  unnecessary  work  on  the  eliminative  organs.  As  a 
general  rule  both  the  number  and  the  bulk  of  meals  is  to  be  reduced, 
and  extractives,  soups,  gravies,  etc.,  are  to  be  avoided.  The  use  of 
fruits  and  vegetables,  especially  if  cooked,  and  if  they  do  not  cause 
flatulence  or  other  symptoms  of  indigestion,  is  to  be  encouraged. 
Freshly  made  cheeses  may  be  taken,  but  those  which  have  been 
ripened  must  be  avoided,  since  they  contain  oxyphenylethylamin,  a 
bacterial  decomposition  product  with  marked  pressor  potency  and 
identical  with  one  of  the  toxic  bases  to  which  ergot  owes  its  effects.* 

Conservation  of  Energy. — In  the  early  stages  of  increased  blood- 
pressure  the  proper  regulation  of  the  daily  life  and  diet  is  the  only 
rational  or  efficacious  method  of  treatment.  The  avoidance  of 
hurry  and  worry  are  of  prime  importance,  and  these  factors  are 
often  the  most  difficult  matters  to  correct.  The  patient  should 
understand  that  the  "doing  of  things  against  time,"  the  attention 
to  several  things  at  once,  the  ceaseless  mental  concentration  upon 
different  problems,  the  assuming  of  unnecessary  tasks  and  responsi- 
bilities, the  frequent  interruption  of  a  train  of  thought  by  telephone 
calls,  etc.,  are  unwarranted  drains  upon  vital  energy,  and  that  he 
who  leads  the  high-pressure  life  is  a  physiological  spendthrift  who 
is  bound  to  end  in  early  bankruptcy.  This  applies  with  special 
emphasis  to  that  class  of  high-strung  individuals  who  "go  on  their 

•  For  literatvtre  see  Edit.  Jour.  Am.  Med.  Assn.,  October  17,  1914. 


320  TREATMENT  OF  ARTERIAL  HYPERTENSION 

nerves,'.'  and  who,  as  Holmes  has  said,  "put  energy  out  at  interest 
and  receive  nervous  derangement  in  return."  "Worry,  suspense, 
anxious  anticipation,  disappointment,  consciousness  of  failure  or 
of  failing  health,  the  hunted  feeling  that  comes  of  overwork,  and 
arrears,  regret,  sorrow,  despair'"^ — "w^ear  out  not  only  the  nervous, 
but  also  the  cardiovascular  system."     (Bruce.) 

Fluid. — Too  much  fluid  throws  an  unnecessary  burden  on  the 
kidneys.  The  old  idea  of  flushing  out  the  system,  of  diluting  toxic 
products,  etc.,  in  patients  already  dropsical  has  been  shown  to  be 
erroneous.  The  total  intake,  in  whatever  form,  should  in  non- 
dropsical  patients  not  exceed  or  fall  below  two  liters  per  diem. 
A  tumblerful  of  hot  water  flavored  with  lemon  juice  or  rind,  or 
with  the  addition  of  citrate  of  potassium,  between  meals  and  at 
bedtime  is  often  beneficial.  It  is  sometimes,  although  rarely, 
advisable  to  diminish  the  fluid  intake  even  in  cases  free  from 
dropsy.  This  should  not  be  done  if  there  is  nitrogen  retention  in 
the  blood.  A  morning  draught  consisting  of  potassium  nitrate, 
grs.  XX,  sodium  nitrate,  grs.  ^-2,  and  potassium  bicarbonate,  grs.  xx, 
in  a  tumblerful  of  water,  has  been  recommended  by  Sir  Lauder 
Brunton. 

Hogan^  has  administered  intravenously,  saline  solution  containing 
sodium  carbonate  (20  gm.  cryst.,  2000  c.c.)  in  cases  of  high  blood- 
pressure  associated  with  uremia  and  believes  that  he  produced  a 
marked  fall  of  pressure,  with  sudation  and  sjTiiptomatic  ameliora- 
tion. He  explains  this  as  due  to  the  fact  that  if  the  concentration  of 
the  infusion  is  right,  "the  tissues  and  blood  colloids  are  robbed 
of  their  water,  and  while  tissue  edema  and  high  blood-pressure  are 
decreased,  free  water  is  made  available  for  excretion  as  urine,  sweat 
and  intestinal  fluid." 

Alcohol  is  contra-indicated.  In  small  well-diluted  doses  it  may 
do  no  great  harm,  but  when  possible  it  should  be  eliminated  entirely. 
The  use  of  tobacco  should  be  restricted.  Smoking  causes  more 
marked  increase  of  blood-pressure  in  hypertensive  than  in  normal 
subjects.  This  rise  of  pressure  is  not  infrequently  associated  with 
palpitation,  vertigo,  insomnia,  nervousness,  precordial  distress, 
and  tremor^  (see  Tobacco  and  Blood-pressure,  page  235). 

Hydrotherapy. — Warm  baths  are  valuable  depressor  remedies, 
and  an  occasional  Turkish  or  electric-light  bath  is  often  useful, 
although  these  procedures  must  never  be  prescribecl  without  due 

>  Alleged  Danger  of  Intravenous  Injections  in  High  Blood-pressure,  Lancet-Clinic, 
January  2,   1915. 

'  Barazzoni,  C. :  Cura  dell'  ipertensione  arteriosa  mediante  la  D'Arsonval- 
izzazione,  Gaz.  med.  Italiana,  1905,  Ivi,  113. 


HOT  BATHS  321 

consideration  of  the  possible  deleterious  effects,  i.  e.,  marked 
temporary  increase  in  blood-pressure  before  sweating  occurs, 
vascular  rupture,  cardiac  strain,  and  reduction  of  nervous  tone. 
Saline  haths  (one  pound  of  washing  soda  or  sodium  chloride  to  the 
tub)  are  more  stimulating  and  produce  more  marked  sudation. 
Nauheim  baths  are  especially  useful  if  there  be  cardiac  dilatation 
or  weakness. 

A  good  sweat  often  causes  a  10  to  20  mm.  fall  in  pressure,  which 
tends  to  last  throughout  the  day,  especially  if  the  procedure  be 
repeated  daily.  Occasionally,  for  reasons  not  yet  understood,  a  series 
of  sweats  will  reduce  the  pressure  for  weeks  or  months.  This 
method  of  treatment  is  of  course  specially  indicated  if  there  be  renal 
insufficiency  or  threatened  uremia,  but  the  occasional  employment 
of  sweat-producing  hydrotherapy  is  often  advisable  in  the  absence 
of  these  conditions.  Just  how  it  does  good  in  uremia  is  uncertain. 
The  amount  of  urea  eliminated  through  the  skin  even  with  a  copious 
sweat  cannot  exceed  10  to  15  grains,  and  it  is  improbable  that  other 
toxic  products  are  thrown  off  in  any  greater  proportions.  It  has 
been  shown  that  the  relative  concentrating  power  of  the  skin  and 
kidney  for  urea  and  ammonia  are  very  different,  though  in  each 
instance  the  values  are  higher  than  in  the  blood. ^  Further  investi- 
gations may  teach  us  that,  depending  upon  the  character  of  the 
toxin  to  be  eliminated,  sweat  baths  may  be  definitely  indicated 
or  contra-indicated  in  a  given  case.  The  beneficial  effects  are 
probably  brought  about  by  a  change  in  the  mass  movement  and  a 
redistribution  of  the  blood,  especially  that  in  the  splanchnic  domain; 
the  peripheral  arterioles  and  capillaries  being  temporarily  dilated 
and  flushed  with  blood.  According  to  Amblard,  electric-light  baths 
produce  less  primary  rise  in  pressure,  and  are  therefore  to  be  pre- 
ferred.       • 

After  the  sweat  the  patient  should  be  allowed  to  cool  off  gradu- 
ally, being  first  wrapped  in  blankets,  and  after  a  time  sponged 
or  sprayed  with  cool  water  or  alcohol.  A  sudden  plunge  in  a  cold 
pool  or  immersion  under  a  cold  shower  bath,  especially  while  the 
patient  is  still  actively  perspiring,  may  produce  an  increase  of  50 
mm.  in  blood-pressure,  an  occurrence  which  throws  a  tremendous 
strain  on  the  cardiovascular  system. 

Hot  Baths. — "  (1)  Baths  with  a  temperature  below  the  indifferent 
zone  (33°  to  35°  C;  91.4°  to  95°  F.),  produce  an  increased  blood- 

'  Plaggemeyer,  H.  W.,  and  Marshall,  E.  K. :     A  Comparison  of  the  Excretory  Power 
of  the  Skin  with  that  of  the  Kidney  through  a  Study  of  Human  Sweat,  Arch.  Int. 
Med.,  1914,  xiii,  159. 
21 


322 


TREATMENT  OF  ARTERIAL  HYPERTENSION 


pressure,  lasting  throughout  the  bath,  with  a  decrease  in  the  pulse 
rate.  (2)  If  the  temperature  be  approximately  40°  C.  (104°  F.), 
after  a  short  initial  rise,  a  lowering  of  the  blood-pressure  to  or  below 
the  normal  occurs;  this  lowering  is  then  followed  by  a  second 
increase  in  the  pressure.  Below  37°  C.  (98.6°  F.),  the  pulse  rate 
is  lowered,  above  this  point  it  is  increased.    (3)  Baths  over  40°  C. 


TIME  IN  MINUTES 
20        ;»       40        50       60 


=>39° 


38° 


37° 


120 


110 


100 


90 


80 


70 


50 


40 


blood  pressure 
■diastolic) 

p'"  g"^  pressure  (amplitude) 

«_«_  pulse  rate 

bodily  temperature  c. 

Fig.  101.— Chart  showing  the  effect  of  a  tub  bath  of  41°  C.  (105°  F.)  upon  the 
blood-pressure,  pulse  rate,  and  bodily  temperature.  The  vertical  lines  indicate  the 
beginning  and  end  of  the  bath.     (After  Strassburger.) 

(ID4°  F.),  produce  an  increase  in  pressure  lasting  throughout  the 
entire  bath,  with  an  increase  of  the  pulse  rate."^ 

Hot  baths  may  produce  weakness,  syncope  or  anginoid  pains  in 
arteriosclerotic  subjects,  if  the  temperature  be  too  high  or  the 
immersion  too  long.    Kerr,^  who  has  reported  some  cases,  attributes 


•  Miiller,  O.,  and  Forchheimer:     Therapeusis  of  Internal  Diseases,  iii,  618. 
'  The  Danger  of  Baths  in  Patients  Suffering  from  Arteriosclerosis,  California  State 
Jour.  Med.,  July,  1916. 


COLD  BATHS  323 

the  anginoid  attacks  to  the  increased  pulse  rate  and  the  increased 
cardiac  load  which  results  from  a  marked  lowering  of  the  diastolic 
pressure.  Hot-air,  steam,  and  electric-light  baths  exercise  effects 
proportional  to  their  temperature.  Hot  baths  must  be  employed 
with  caution  in  the  treatment  of  hypertension  in  diabetes.  It  has 
been  shown  that  if  the  bodily  temperature  be  raised  either  by  fever 
or  by  artificial  means  the  sugar  content  of  the  blood  increases.^ 

Foot  Baths. — Hot  foot  baths,  to  which  mustard  may  be  advan- 
tageously added,  are  often  a  satisfactory  treatment  for  the  headache 
and  insovinia  of  hypertension.  If  the  patient  is  to  sleep,  the  feet 
must  be  kept  warm,  and  for  this  purpose  a  hot-water  bag  in  bed 
is  often  desirable. 

Cold  Baths. — The  application  of  cold,  especially  in  the  form  of 
forcible  sprays  and  douches  (mechanical  stimuli),  increases  blood- 
pressure.  The  lower  the  temperature  and  the  more  sudden  the 
application,  the  greater  the  rise.  A  sudden  plunge  into  a  cold  pool, 
accompanied  by  the  additional  muscular  efforts  of  swimming, 
produces  a  great  increase  in  pressure,  quite  sufficient  in  arterio- 
sclerotic cases  to  cause  vertigo  and  precordial  oppression,  to  pre- 
cipitate an  apoplexy,  an  attack  of  angina  pectoris,  or  of  pulmonary 
edema. 

In  normal  individuals  the  vascular  reaction  to  heat  and  cold  are 
general  reactions,  i.  e.,  a  cold  bath  reduces  peripheral  blood  flow 
and  temperature,  not  only  in  the  parts  immersed  but  elsewhere. 
Even  sitz  baths  have  a  similar  effect,  although  the  idea  still  persists 
in  some  minds  that  blood  is  simply  crowded  out  of  the  area  to 
which  the  cold  is  applied  and  forced  into  other  peripheral  areas. 
This  has  been  shown  to  be  incorrect.  In  abnormal  conditions, 
however,  whether  functional  or  organic  in  origin,  local  peripheral 
variations  may  occur.  The  peripheral  application  of  cold  produces 
cerebral  hyperemia,  whereas  heat  has  the  opposite  effect.  It 
also  decreases  systolic  output,  whereas  hot  baths  increase  the 
latter.  It  should  be  remembered,  however,  that  where  sensory 
stimuli  (friction,  CO2,  etc.)  are  added  to  the  cold  bath  the  systolic 
output  may  be  increased  despite  the  low  temperature  of  the  bath. 
Following  a  cold  bath  the  reaction  becomes  reversed,  the  systolic 
output  is  increased  and  peripheral  vascular  dilatation  occurs. 
When  the  circulatory  apparatus  is.  efficient  or  if  the  cold  bath  has 
been  preceded  by  sweating,  etc.,  the  reversed  reaction  may  set  in 
even  while  the  subject  is  still  in  the  cold  bath.      The  changes  in 

'  Roily,  F.,  and  Oppermann:     Das  Verbal  ten  des  Blutzuckers  b.  Gesunden  u. 
Kranken,  Biochem.  Ztschr.,  1913,  xlvii,  187. 


324  TREATMENT  OF  ARTERIAL  HYPERTENSION 

blood-pressure  which  result  from  sensory  or  thermic  stimuli  are 
dependent  both  upon  the  state  of  the  splanchnic  veins  and  upon 
that  of  the  peripheral  arterioles.  Blood-pressure  may  increase 
despite  splanchnic  dilatation  as  a  result  of  peripheral  contraction 
(cold  baths,  etc.),  so  long  as  the  splanchnic  vessels  retain  their 
tone. 

A  cold  bath  is  by  far  the  viost  potent  remedy  which  we  possess 
for  altering  blood  distribution.  It  adds,  however,  a  distinct  burden 
upon  the  heart.  Spray  and  shower  baths  still  further  increase 
the  burden  by  the  sensory  stimulation  which  they  provoke.  If 
the  heart  is  weak,  instead  of  a  rise  in  pressure,  cold  baths  may 
actually  cause  a  fall,  because  the  heart  weakens  instead  of  responding 
to  the  call  for  increased  effort.  Indeed,  syncope  and  sudden  death 
may  thus  be  precipitated.  Nature,  it  appears,  often  wards  off  the 
latter  events  by  rendering  vasomotor  nerves  reactionless. 

O.  Miiller  has  shown  that  not  infrequently  the  peripheral 
arteries  of  cardiopaths  are  plethysmographically  irresponsive  to 
the  local  application  of  ice.  It  must  be  remembered,  however, 
that  although  this  may  be  true  for  minor  reactions,  such  as  those 
just  mentioned,  nevertheless  a  major  reaction  such  as  that  produced 
by  a  cold  bath  may  be  suddenly  fatal.  With  diseased  arteries 
the  sudden  elevation  of  pressure  which  follows  a  cold  bath  may 
produce  vascular  rupture.^ 

Too  frequent  or  too  vigorous  hydr other apeutic  measures  tend  to 
lower  nerve  tone  and  may  do  actual  harm.  In  the  thin,  high-strung, 
hypertensive  patient  they  must  be  used  with  caution.  Too  violent 
forcing  down  of  the  arterial  pressure  by  means  of  baths,  etc.,  is 
just  as  reprehensible  as  when  the  same  end  is  attained  by  means  of 
the  nitrites.  If  the  patient  feels  listless,  weak,  or  exhausted,  as  a 
result  of  the  baths,  they  are  doing  him  harm,  despite  the  fact  that 
his  pressure  may  be  more  nearly  normal.  Cold  baths  although 
increasing  the  arterial,  lower  the  capillary,  blood-pressure.  The 
effect  of  hot  baths  upon  the  capillary  pressure  is  less  constant 
(Landerer) . 

Carbonated  Brine  Baths. — Despite  the  fact  that  Miiller  and  Weiland 
have  furnished  plethysmographic  evidences  of  peripheral  vaso- 
constriction, and  Liwschutz  tachographic  indications  of  an  increased 
systolic  output,  it  must  be  confessed  that  in  a  large  number  of 
cases  treated  with  carbonated  brine  baths  no  constant  pressure 
effects  can  be  demonstrated. 

1  This  subject  has  been  admirably  summarized  by  O.  Miiller  and  E.  Veiel :  Samml. 
klin.  Vortrage,  1909-10,  N.  F.,  167-196  (innere  medizin),  p.  641. 


CARBONATED  BRINE  BATHS  325 

The  pressure  at  the  end  of  the  bath  or  upon  the  completion  of 
the  treatment,  in  cases  either  of  hypertension  or  of  hypotension,  is 
variable.  On  the  whole,  pressure  is  more  frequently  raised  than 
lowered,  but  it  is  impossible  to  know  beforehand  in  which  way  a 
given  case  may  respond.^  J.  H.  Pratt^  found  that  in  patients  with 
normal  or  only  slightly  insufficient  hearts,  carbon  dioxide  baths 
(95°  to  85°  F.),  usually  raised  systolic  pressure.  The  pulse  rate, 
while  usually  lowered  may  be  increased.  There  is  no  relation 
between  the  effect  of  baths  upon  these  two  factors.  In  normal 
subjects  identical  successive  baths  may  have  diametrically  opposite 
results  in  the  same  individual.  The  pulse-pressure  is  often  but  not 
invariably  increased  by  cool  carbon  dioxide  baths;  it  may,  however, 
be  decreased.  We  do  not  mean  to  derogate  the  usefulness  of  this 
form  of  treatment,  which  is  often  followed  by  excellent  results, 
especially  in  cases  of  cardiac  weakness,  but  merely  to  point  out 
that  neither  the  subjective  nor  objective  improvement  rests  on  a 
basis  of  blood-pressure  change. 

Even  less  marked  and  less  constant  results  are  observed  after 
the  use  of  alternating  current  baths  .^ 

The  organism  reacts  to  electric  stimulation  (faradic,  galvanic 
or  alternating  currents)  by  a  negative  volume  change  as  shown  by 
the  plethysmograph.  The  effect  upon  the  pulse  rate  and  the  blood- 
pressure  is  inconstant  both  in  the  same  and  in  different  individuals. 
Whether  the  benefits  which  sometimes  follow  electric  baths  in 
cardiac  disease  are  due  to  cutaneous  reflexes  or  to  muscular  con- 
traction is  uncertain.* 

The  effects  of  the  baths  depend  largely  on  the  temperature.  If 
below  33°  to  35°  C.  (92°  to  95°  F.)  the  pressure  will  be  more  apt  to 
rise,  if  above  this  point,  to  fall.  But  with  temperatures  above 
40°  C.  (104°  F.)  the  pressure  first  rises  and  later  falls.  Hot  and 
cold  douches  elevate  and  lukewarm  douches  lower  tension.  The 
effect  on  the  pulse  rate  is  equally  important,  heat  accelerating  and 
cold  retarding  it.  These  effects  are  generally  transient,  not  lasting 
more  than  an  hour  or  two. 

Exception  is  often  taken  to  the  fact  that  carbon  dioxide  baths 
are  used  both  in  the  treatment  of  arterial  hypotension  and  hyper- 

1  Swan,  J.  M.:  The  Influence  of  Caibonated  Brine  (Nauheim)  Baths  on  Blood- 
pressure,  Arch.  Int.  Med.,  1912,  x,  73. 

^  Action  of  Carbon  Dioxide  Baths  on  the  Blood-pressure  in  Cardiac  Disease,  Tr. 
Am.  Climat.  Soc,  1913,  xxix,  252. 

'  Laquer,  A.:  Ueber  d.  Verhalten  des  Blutdruckes  nach  Kohlensaure  u.  Wechsel- 
strombadern,  Ztschr.  f.  exp.  Path.  u.  Therap.,  1909,  vi,  855. 

^Geissler:  Der  Einfluss  Elektrischer  Reize  auf  d.  Blutvertheilung  ira  Mensch- 
lichen  Korper,  Miinchea.  med.  Wchnschr.,  1908,  Iv,  92. 


326  TREATMENT  OF  ARTERIAL  HYPERTENSION 

tension.  Their  beneficial  effects,  which  are  unquestionable,  are 
to  be  explained  thus :  The  baths  have  essentially  a  cardiovascular 
tonic  effect.  Ordinarily  they  are  followed  by  a  rise  in  blood-pressure, 
an  increased  systolic  output,  and  a  slowing  of  the  pulse.  This 
leads  to  a  generally  improved  circulation,  nutrition,  and  excretion, 
and  may  indirectly  lower  blood-pressure,  especially  in  cases  of 
high-pressure  stasis.  Their  action  is  thus  comparable  to  that  of 
digitalis.  Those  most  competent  of  judging,  state  that  these  baths 
are  harmful  in  cases  of  advanced  renal  lesions.  This  is  probably 
due  to  the  temperature  (83°  to  90°  F.)  to  which  the  baths  are 
lowered,  for  certainly  the  secretion  of  sweat  and  urine  is  distinctly 
increased  in  the  average  case  to  which  this  treatment  is  given. 

Cool  carbon  dioxide  baths  slow  the  heart  and  cause  contraction 
of  the  peripheral  arterioles.  The  thick  layer  of  bubbles  which 
surrounds  the  body  in  part  prevents  the  loss  of  heat  which  occurs 
in  ordinary  cool  baths,  thus  causing  a  pleasant  sensation  of  warmth. 
Warm  carbon  dioxide  baths  increase  the  pulse  volume,  but  have 
the  opposite  effect  from  cool  baths  upon  the  arterioles.  Since 
these  baths  make  considerable  demands  upon  the  circulation  they 
must  only  be  given  under  medical  supervision. 

Oxygen  Baths. — Oxygen  baths  have  been  extensively  employed 
as  a  remedial  measure  in  cases  of  arterial  hypertension,  and  are 
said  by  numerous  observers  to  be  attended  with  very  satisfactory 
results.  A  lowering  of  tension  is  more  constant  than  in  the  case 
of  carbon  dioxide  baths.  These  baths  are  contra-indicated  in  the 
terminal  hypotension  of  arteriosclerosis  (Winternitz),^  especially  if 
associated  with  anemia  (Baedeker)  .^ 

The  baths  which  may  be  administered  at  home^  are  given  at  a 
temperature  of  90°  to  95°  F.,  for  from  ten  to  twenty-five  minutes. 
A  course  of  baths  (twenty-four)  should  be  given  on  successive,  days, 
with  occasional  intermissions,  either  in  the  morning  or  at  night 
(for  insomnia),  but  not  too  soon  after  a  meal. 

Precordial  Aplications. — The  application  of  cold  to  the  precordium 
bdth  experimentally  and  clinically^  tends  to  slow  the  heart  rate, 
to  increase  blood-pressure  and  to  diminish  systolic  output.  These 
changes  are  produced  in  part  refiexly  and  in  part  directly  through 
reduction  of  the  myocardial  temperature.    The  increased  pressure 

>  Blatter  f.  klin.  Hydrother.,  1907,  p.  1. 

2  Ther.  d.  Gegenwart,  1910,  p.  2. 

'  "Perogen"  baths.  Morgenstern  &  Co.,  New  York.  The  oxygen  is  liberated  by 
the  admixture  in  the  bath  of  two  powders  (sodium  perborate  and  magnesium  borate). 

^  Hirschfcld,  A.,  and  Lewin,  H. :  Untersuchung  ueber  die  Wirkung  des  Herzsch- 
lanches,  Ztschr.  f.  Physik.  u.  Diat.  Therap.,  1914,  xviii,  6. 


BANDAGING  OF  THE  EXTREMITIES  327 

is  secondary  to  vascular  contraction.  Hot  precordial  applications, 
on  the  other  hand,  raise  blood-pressure  despite  peripleural  vaso- 
dilatation and  this  is  probably  due  to  an  increased  systolic  output. 

It  is  obvious  therefore  that  the  application  of  ice-bags  may  be 
injurious  to  a  diseased  myocardium  which  is  already  pushed  to  its 
limit  while  in  the  same  case  the  local  use  of  heat  might  be  directly 
beneficial. 

Phlebotomy. — ^Venesection  is  one  of  the  most  prompt  and  effica- 
cious methods  of  lowering  blood-pressure  and  relieving  a  distended 
right  heart.  Its  beneficial  effects  in  uremia  are  generally  attributed 
to  the  foregoing  effects  and  not  to  the  amount  of  toxic  material 
which  is  removed  from  the  blood  stream.  Phlebotomy  is  chiefly 
indicated  in  conditions  of  venous  stasis,  whether  due  to  right  or 
left  ventricular  weakness.  It  often  yields  excellent  results  in  the 
treatment  of  aortic  aneurysm  and  of  acute  pulmonary  edema.  In 
order  to  obtain  definite  results  300  to  500  c.c.  of  blood  must  be 
withdrawn.^  A  rapid  venesection  amounting  to  from  300  to  500  c.c. 
will  generally  reduce  blood-pressure  from  5  to  30  mm.  As  a  rule  the 
more  rapid  the  withdrawal  the  more  pronounced  the  fall  of  press- 
ure. The  symptomatic  relief  afforded  is  sometimes  immediate — 
even  before  an  appreciable  quantity  of  blood  has  been  withdrawn. 
This  fact  shows  that  mere  section  of  the  vein  produces  some 
definite  reflex  action  probably  through  the  medium  of  the  nervi 
vasorum. 

Bandaging  of  the  Extremities. — The  application  of  tourniquets  to 
the  extremities  with  sufficient  constriction  to  prevent  venous 
outflow,  although  allowing  arterial  inflow,  has  temporarily  much 
the  same  effect  upon  the  system  as  a  phlebotomy.  It  has  been 
recommended  as  a  method  of  treating  heart  weakness,  but  has 
not  found  much  favor.  If  too  much  pressure  is  exerted,  inhibition  of 
arterial  inflow  and  marked  increase  of  general  blood-pressure  will 
result.  The  method  must,  of  course,  not  be  applied  in  the  presence 
of  edema  or  varicose  veins  of  the  extremities.  Relaxation  of  the 
bandages  must  always  be  gradual  so  as  not  to  suddenly  increase 
cardiac,  work.  By  bandaging  all  four  extremities  20  per  cent,  of 
blood  can  be  removed  from  the  general  circulation  and  the  heart 
spared  a  corresponding  amount  of  energy.  Subjective  symptoms 
are  said  to  show  a  distinct  amelioration.^  This  procedure  has 
been  useful  in  cases  of  threatened  pulmonary  edema  and  other 
conditions  associated  with  increased  venous  pressure.    Pronounced 

1  Moritz  and  Tabora:  Verhandl.  d.  Kong.  f.  inn.  Med.,  1909,  xxxvi,  378. 

2  LilliensteJn :  Der  unblutige  Aderlass,  Phlebostase,  Med.  Klinik,  1912,  vii,  316. 


328  TREATMENT  OF  ARTERIAL  HYPERTENSION 

passive  congestion  in  the  extremities  may  cause  a  fall  of  20  mm. 
Ilg.,  sometimes  rather  suddenly,  with  signs  of  collapse. 

High-frequency  Currents.^ — Although  there  is  as  yet  no  unanimity 
of  opinion  on  the  subject,  some  very  favorable  reports  have  been 
published  regarding  the  efficacy  of  high-frequency  currents  for  the 
reduction  of  high  arterial  pressure.  The  current  is  said  to  act 
by  lowering  peripheral  resistance  and  also  by  acting  as  a  cardiac 
tonic. 

Nagelschmidt,^  who  reports  good  results  in  a  series  of  120  cases, 
believes  that  the  discrepancies  in  the  results  attained  by  different 
observers  with  the  high-frequency  current  are  due  to  the  fact  that 
an  insufficient  amperage  has  generally  been  employed. 

The  exact  means  by  which  high-frequency  currents  reduce  blood- 
pressure  are  not  thoroughly  understood.  The  belief  at  present 
is  that  the  effect  is  mainly  thermal  (local  heating,  rise  of  bodily 
temperature,  and  pulse  rate,  sudation  and  peripheral  vasodila- 
tation) and  that  it  is  not  due  to  cardiac  depression. 

"If  two  electrodes  from  a  galvanic  or  a  faradic  current  are  placed 
in  a  bowl  of  water,  decomposition  occurs  with  bubbles  at  either 
pole.  Even  if  quite  weak,  a  hand  placed  between  them  experiences 
.painful  electrolytic  sensations.  If  these  electrodes  are  replaced 
by  high-frequency  ones,  hardly  any  electrolysis  occurs.  The  water 
merely  gets  warm,  and  a  hand  placed  between  them  experiences  no 
sensation  whatever  excepting  that  of  warmth,  even  with  currents 
so  strong  that  were  they  galvanic  or  faradic  they  would  cause 
chemical  and  electrolytic  changes  capable  of  destroying  the  tissues" 
(Sayer)  .^ 

"With  regard  to  alterations  in  the  blood  itself,  we  may  look 
upon  the  action  of  high  frequency  in  reducing  blood-pressure  as 
being  in  some  way  analogous  to  the  action  of  a  rise  of  temperature, 
when,  unless  there  is  dyspnea  and  cyanosis,  the  rapid  metabolism 
caused  by  the  onset  of  any  fever  is  always  accompanied  by  a  fall 
in  blood-pressure,  an  increased  excretion  of  uric  acid,  and  a  quick 
capillary  reflux,  exactly  what  happens  on  a  small  scale  with  a  dose 
of  high  frequency." 

'  Also  spoken  of  as  Arsonvalization  after  d'Arsonval,  to  whose  physiological  studies 
so  much  of  our  present  knowledge  on  the  subject  is  due.  For  further  information 
regarding  the  history,  electric  data,  detailed  description,  and  literature  on  this  sub- 
ject see  Allen,  W.  C. :  Radiotherapy  and  Phototherapy,  Philadelphia,  1904.  Mann, 
L.:  Krause  and  Garie's  Lehrbuch  d.  Ther.  Inneren  Krankheiten,  1911,  i,  488,  509. 

*  Diathermic  Treatment  of  Circulatory  Disorders,  Arch.  Rontgen  Ray,  February, 
1912. 

'  The  Effects  of  Electrical  Currents  upon  Blood-pressure,  British  Med.  Jour., 
October  8,  1910,  p.  1052. 


HIGH-FREQUENCY  CURRENTS  329 

The  effect  on  the  nervous  system  is  definite,  but  the  sensory  and 
motor  stimuU  are  too  rapid  to  permit  of  a  response,  "for  all  electric 
vibrations  beyond  ten  thousand  per  second  lie  beyond  the  limits 
of  the  range  of  frequencies  to  which  these  nerves  can  respond. 
Although  no  direct  effects  can  be  demonstrated,  yet  their  applica- 
tion to  any  muscle  or  nerve  does  in  some  way  affect  it,  for  it  is 
found  afterward  that  its  excitability  to  all  ordinary  electric  (gal- 
vanic and  faradic)  stimulation  is  lessened"  (Sayer).  The  high- 
frequency  currents  act  specially  upon  the  nerves  of  the  vasomotor 
system,  the  splanchnics  and  the  large  sympathetic  trunks  and 
the  greatest  effects  are  produced  if  the  current  is  passed  through 
these  tissues.  In  nerves  containing  both  constrictor  and  dilator 
fibers,  ordinary  electric  stimulation  produces  a  more  marked  effect, 
especially  if  weak  currents  are  employed  (Crile). 

Method  of  Application. — I.  Induction. — ^The  patient  is  placed 
in  the  centre  of  a  wire  cage,  through  the  wires  of  which  the  current 
is  passed.    An  induction  current  is  thus  generated  in  the  patient. 

The  presence  of  such  a  current  can  be  demonstrated  by  means 
of  an  incandescent  globe,  held  in  the  hand  of  the  patient,  which 
without  any  direct  connection  with  the  solenoid  will  become 
luminous  (Mann). 

II.  Condensation.— When  the  patient  rests  on  an  insulated  couch 
or  chair  cushion,  a  high-frequency  current  derived  from  a  static 
machine,  or  preferably  from  a  specially  designed  apparatus,  is 
passed  through  his  body,  using  either  a  monopolar  or  a  bipolar 
method  (the  patient  being  connected  with  the  circuit  by  one  or 
two  pole  electrodes,  and  acting  as  a  current  condenser).  The 
strength  of  the  current  passing  through  the  coil  is  gauged  by  an 
amperemeter,  while  the  amount  received  by  the  patient  can  be 
gauged  with  a  milliamperemeter  placed  between  the  table  and  the 
couch.  Burch^  has  reported  untoward  results  in  some  cases.  He 
found  that  if  patients  who  scarcely  responded  to  from  20  to  50 
milliamperes  were  subjected  to  200  to  800  milliamperes  a  very 
marked  fall  of  pressure  with  signs  of  collapse  sometimes  occurred. 
Patients  who  readily  respond  to  the  smaller  dose  are,  he  believes, 
instances  of  spastic  hypertension  which  cannot  safely  be  treated 
with  the  heavier  dosage.  The  cases  that  show  no  response  to  the 
milder  current  show  the  best  results  under  the  larger  dosage.  These 
cases  are  supposedly  due  to  both  a  vasomotor  spasm  and  a  vascular 
degeneration  with  a  relatively  strong  heart. 

1  Electrical  Treatment  of  Arterial  Hypertension,  Med.  Record,  1911,  Ixxx,  866. 


330  TREATMENT  OF  ARTERIAL  HYPERTENSION 

III.  Local  Application.  (Diathermic  Method.) — By  means  of 
electrodes  of  different  kinds  the  current  is  conducted  from  a  small 
solenoid  to  the  patient.  In  order  to  insure  greater  penetration  and 
to  minimize  the  local  effect  which  this  mode  of  application  chiefly 
favors,  the  current  is  taken  froin  an  alternating  current  generator 
and  then  interrupted  by  means  of  a  jump-spark  attachment.  The 
action  of  this  (diathermic)  current  is  somewhat  different  from 
that  of  d'Arsonval  (Mann).  There  is  no  cutaneous  resistance. 
The  current  passes  from  one  electrode  to  another  by  the  shortest 
route,  permeating  the  intervening  tissues  with  practically  equal 
intensity.  It  is  claimed  that  blood-pressure  can  be  (1)  raised,  by 
precordiodorsal  application,  as  the  result  of  cardiac  stimulation 
and  cutaneous  irritation,  and  (2)  lowered,  through  peripheral 
dilatation,  by  application  to  the  central  nervous  system  (medulla). 
When  one  desires  to  heat  the  heart  muscle  itself,  the  large  indifferent 
electrode  is  placed  over  the  dorsal  region,  the  smaller,  movable 
one  over  the  precordium.  The  latter  must  be  so  constructed  that 
it  is  possible  to  pass  1000  to  1200  milliamperes  for  at  least  five 
minutes  without  undue  heating  of  the  skin  (Nagelschmidt). 

Indications. — High-frequency  currents  yield  the  best  effects  in 
cases  of  spastic  hypertension  with  relatively  good  heart  muscle 
and  kidneys.  The  effects  produced  are  said  to  be  more  lasting 
than  those  resulting  from  the  use  of  vasodilator  drugs.  They  can 
lead  to  permanent  benefit  only  when  coupled  with  hygienic  and 
dietetic  correction.  Too  great  a  fall  of  pressure  as  the  result  of 
such  therapeusis  may,  according  to  Moutier  and  Challamal,^  be 
counteracted  by  the  application  of  this  current  to  the  vertebral 
column.  According  to  Fontana^  the  variable  results  obtained  by 
high-frequency  currents  upon  blood-pressure  depend  upon  the 
permeability  of  the  kidneys.  The  vascular  dilatation  and  increased 
metabolism  which  the  current  produces  throws  extra  work  on  the 
kidneys  which,  if  these  organs  are  functionally  active,  causes  a 
fall  of  blood-pressure,  whereas  insufficient  kidneys  fail  to  react 
and  blood-pressure  remains  high. 

Massage.— Although  the  primary  effect  of  massage,  as  the  result 
of  cutaneous  stimulation,  tends  to  raise  blood-pressure,  this  effect 
is  more  than  counter-balanced  by  its  effect  on  lymphatic  and  venous 
flow.    Good  general  massage,  especially  in  association  with  Swedish 

•  De  rabaissement  de  la  pression  arterielle  au  dessous  de  la  normale  par  la  d'arson- 
valizatjon,  Compt.  rend.  Acad.  d.  sci.,  Paris,  1905,  cxl,  742. 

^  Dell'azione  delle  correnti  ad  alta  frequenza  sulla  pussione  arteriosa  in  rapporto 
alia  permeabilita  renale,  Gazz.  d.  Ospedali  e.  d.  Clin.,  1914,  xxxv,  523. 


CUTANEOUS  IRRITATION  331 

movements,  is  one  of  the  most  usejul  measures  which  can  be  employed 
in  the  treatment  of  arterial  hypertension.  It  supphes  many  of 
the  benefits  of  exercise  without  the  attendant  expenditure  of  energy. 

Abdominal  Massage. — Some  authorities  hold  that  this  form  of 
massage  is  contra-indicated  in  cases  of  hypertension  and  cardiac 
disease.  Experimentally  in  animals  it  increases  blood-pressure, 
but  some  clinical  observations  show  that  this  is  by  no  means  always 
the  case.  Indeed,  a  fall  of  pressure  may  be  observed.  Certainly 
compression  of  the  large  abdominal  arteries  tends  to  raise  the 
general  pressure  at  least  temporarily,  but  generally  (with  judicious 
massage)  this  rise  is  slight  and  is  soon  more  than  counter-balanced 
by  the  good  effect  which  the  manipulations  have  upon  digestion 
and  intestinal  peristalsis. 

When  skilfully  performed  it  has  a  generally  sedative  effect  accom- 
panied by  a  slowing  of  the  pulse  and  often  a  fall  of  blood-pressure, 
probably  by  its  influence  on  local  stasis  in  the  mesenteric  vessels, 
although  vagus  action  may  have  a  part  in  the  results.^ 

Vibratory  Massage. — This  form  of  massage  yields  good  results, 
requires  less  time,  and  does  not  necessitate  undressing,  but,  as  a 
therapeutic  measure,  it  is  less  satisfactory  than  good  general 
massage  with  passive  movements.  A  valuable  factor  of  the  latter 
procedure  lies  in  the  hour's  rest  and  relaxation  which  the  patient 
should  be  instructed  to  take  after  its  completion.  Even  prolonged 
vibration  of  the  precordium  is  without  effect  upon  the  pulse  rate, 
the  blood-pressure,  or  the  systolic  output.^  It  has  been  claimed 
that  definite  blood-pressure-lowering  effects  can  be  obtained  by 
concussion  of  the  seventh  cervical  vertebra  for  a  period  of  about 
five  minutes,  and  that  vibration  of  the  sixth  and  seventh  dorsal  ver- 
tebrae tends,  although  less  constantly,  to  increase  vascular  tension.' 

Cutaneous  Irritation. — Local  irritation  of  the  skin  (mustard, 
capsicum,  etc.),  produces  redness  by  dilatation  of  the  capillaries 
and  venules  without  a  corresponding  dilatation  of  the  underlying 
arterioles.^  Such  methods  of  counter-irritation  find  a  distinct  field 
of  usefulness  when  applied  to  the  feet,  neck,  or  precordium  in  helping 
to  relieve  some  s;yTnptoms  of  hypertension  (insomnia,  headache, 
precordial  and  epigastric  oppression)  as  well  as  in  mitigating  the 
restlessness  and  delirium  of  acute  infections,  notably  of  pneumonia. 

1  Ekgren,  E.:  Ueber  den  Einfiuss  d.  Abdom.  Massage  auf  Blutdruck,  Herzthatig- 
keit  u.  Puis,  etc.,  Ztschr.  f.  diatet.  u.  physik.  Therap.,  1902,  v,  191. 

^  Plate  and  Bomstein:  Ueber  d.  Einfluss  d..  Herzvibration  mit  hoher  Frequenz 
auf  d.  Kreislauf,  ibid.,  1913,  xvii,  65. 

'  Abrams,  A.:  Spondylotherapy,  1910,  p.  248. 

*  Wood  and  Weisman:  Arch.  Int.  Med.,  September,  1912. 


332  TREATMENT  OF  ARTERIAL  HYPERTENSION 

Passive  Exercises. — This  form  of  gymnastics  administered  either 
by  an  attendant  or  by  machinery  (Zander  apparatus,  etc.),  since 
it  supplies  the  beneficial  effects  of  muscular  exertion  without  an 
attendant  expenditure  of  volitional  nervous  energy,  tends  to  lower 
blood-pressure  in  a  satisfactory  manner,  and  is  a  useful  adjunct 
to  other  forms  of  treatment. 

Climate. — A  warm,  equable  climate  is  desirable.  Winters  may 
be  spent  in  Egypt,  Jamaica,  Bermuda,  Southern  California,  etc. 
Moderate  warmth  and  sunshine  conduce  to  outdoor  exercise  which, 
when  accompanied  by  gentle  perspiration,  is  most  desirable,  but 
sudden  chilling  must  be  sedulously  guarded  against  (see  Altitude). 

Psychic  Treatment.— Certain  types  of  high-pressure  individuals 
are  extremely  susceptible  to  suggestion,  and  tend  to  become  intro- 
spective. Cautionary  advice  in  such  instances  must  be  tempered 
with  encouragement.  The  additional  element  of  self-worry  must 
not  be  added  to  their  other  burdens.  For  this  reason  it  is  often 
inadvisable  to  tell  the  patient  anything  about  pressure  changes, 
particularly  if  these  should  happen  to  be  for  the  worse.  The 
beneficial  effects  of  light  exercise  and  diversions  of  different  kinds 
owe  much  of  their  good  effect  to  psychic  impressions. 

Respiratory  Gymnastics. — In  certain  cases  of  hypertension  both 
symptomatic  improvement  and  lowering  of  tension  may  be  induced 
by  breathing  exercises.  Space  will  not  allow  discussion  in  detail  of 
the  mechanism  by  which  this  is  brought  about;  but  such  results 
are  not  difficult  to  understand  when  we  consider  that  better  aeration 
of  the  blood  diminishes  its  centrally  pressure-raising  CO2  content. 
Proper  action  of  the  respiratory  muscles,  especially  of  the  diaphragm, 
facilitates  blood  flow  to  and  from  the  heart,  and  increases  venous 
and  lymphatic  flow  in  the  digestive  organs  and  elsewhere.  Thus 
tissue  metabolism  and  elimination  are  directly  favored. 

That  the  question  is  not,  however,  a  perfectly  simple  one  is 
shown  by  Stewart's  investigations,  which  proved  that  peripheral 
blood  flow  (in  the  hands)  was  diminished  by  deep  breathing. 

"The  cause  of  the  diminution  in  blood  flow  produced  by  forced 
respiration  is  without  question  in  part  a  mechanical  effect  on  the 
action  of  the  heart  due  to  the  changes  in  the  intrathoracic  pressure. 
Hill  and  Flack  have  stated  that  the  left  ventricle  becomes  smaller, 
as  shown  by  Rontgen-ray  pictures,  the  radial  artery  emptier, 
and  the  arterial  blood-pressure  lower  with  each  forced  thoracic 
inspiration.  That  a  chemical  change  may  also  be  concerned  is 
indicated  by  experiments  in  the  case  of  cyanosis  already  mentioned, 
in  which   oxygen   inhalation   distinctly   increased   the  blood  flow 


RADIO-ACTIVE  SUBSTANCES  333 

in  the  hand  without  affecting  the  respiratory  movements  or  the 
total  pulmonary  ventilation,  while  in  normal  persons  it  had  no 
such  effect.  It  may  be  that  the  washing  out  of  the  carbon  dioxide 
by  the  forced  respiration  causes,  even  in  such  short  experiments 
and  with  such  moderate  exaggeration  of  the  respiratory  movements, 
those  changes  in  the  distribution  of  the  blood,  particularly  its 
accumulation  in  the  great  veins,  which  Henderson  associates  with 
'acapnia,'  and  which,  according  to  him,  are  so  important  a  factor 
in  surgical  shock.  Other  vascular  changes — for  example,  a  diminu- 
tion of  the  flow  in  the  coronary  circulation  due  to  the  fall  of  pressure 
in  the  aorta,  which  aid  the  mechanical  changes  in  the  thorax  in 
decreasing  the  average  output  of  the  heart — may  occur.  Changes 
produced  through  the  vasomotor  centre  on  the  peripheral  vessels 
may  also  play  a  more  direct  part.  This  is  at  any  rate  suggested 
by  the  fact  that  the  perceptible  change  in  the  flow  caused  by  forced 
breathing  is  not  the  same  for  the  two  hands,  as  it  might  be  expected 
to  be  were  the  whole  effect  a  cardiac  one.  However,  it  is  not 
intended  to  lay  much  stress  on  this  suggestion,  for  the  initial 
differences  in  the  flow  in  the  two  hands  are  not  sufficiently  great 
to  permit  without  hesitation  the  application  of  this  criterion.  The 
beneficial  influence  of  oxygen  on  the  flow  in  the  case  of  cyanosis 
may  be  explained  as  the  result  of  the  oxygen  action  in  diminishing 
the  excitability  to  carbon  dioxide  of  the  vasomotor  centre  and  other 
mechanisms  affected  by  hypercapnia."^ 

Differential  pressure  in  the  lungs,  breathing  into  rarefied  air, 
has  been  used  as  a  method  of  promoting  blood-circulation.  Bruns 
found  that  when  the  pressure  of  the  air  into  which  the. patient 
breathes  has  been  reduced  to  8  to  10  c.c.  H2O,  both  pulse  and 
respiratory  rate  increase,  peripheral  flow,  as  shown  by  the  plethys- 
mograph,  is  increased  and  venous  pressure  falls.^ 

Radio-active  Substances. — Our  knowledge  of  the  physiological 
effects  of  radio-active  substances  is  very  meager.  The  employ- 
ment of  these  remedies  is  still  in  its  experimental  stage,  and  there 
is  considerable  evidence  to  show  that  the  efficient  therapeutic  dose 
and  the  toxic  dose  are  separated  by  but  a  narrow  margin. 

The  drinking  of  water  charged  with  radium  emanations  appears 
to  increase  tissue  metabolism,  the  activity  of  ferments  and  urinary 
flow.    Good  results  attending  its  administration  in  cases  of  gout  and 

J  Stewart,  G.  N.:  Studies  on  the  Circulation  in  Man,  III.  The  Influence  of 
Forced  Breathing  on  the  Blood  Flow  in  the  Hands,  Am.  Jour.  Physiol.,  1911,  xxviii, 
No.  3,  p.  196. 

2  Bruns,  O.:  Die  kilnstlichc  Luftdruckerniedrigung  u.  d.  Lungen,  etc.,  Miinchen. 
med.  Wchnschr..  1910,  hdi,  2169. 


334  TREATMENT  OF  ARTERIAL  HYPERTENSION 

of  arterial  hypertension  have  been  reported.  It  is  now  generally 
believed  that  the  beneficial  effects  obtained  at  certain  health 
resorts  such  as  Bad  Gastein  in  the  Austrian  Tyrol,  and  Hot  Springs, 
Arkansas,  are  due  to  the  radio-active  waters  there  present. 

Water  charged  with  radium  emanations,  however,  quickly  loses 
its  potency  and  hence  bottled  waters  are  inert.  The  artificial 
cliarging  of  water  with  radium  emanations  is  now,  however,  possible, 
and  favorable  results  may  be  obtained  with  home-charged  water 
having  a  potency  of  5000  to  20,000  Mache  units  when  taken  over 
prolonged  periods  of  time. 

Solutions  of  thorium-X  have  been  administered  intravenously. 
Plesch,  who  employed  this  method  of  treatment  in  pernicious 
anemia,  found  a  considerable  lowering  of  blood-pressure  associated 
with  increased  metabolism,  oxygen  consumption,  and  loss  of  weight. 

The  action  of  vanadium  on  different  organs  and  tissues  is  but 
little  understood.  It  appears  that  the  intravenous  injection  of 
this  substance  in  mammals  is  but  slightly  toxic  to  the  heart.  It 
causes  a  rise  of  blood-pressure  due  to  peripheral  vasoconstriction, 
but  repeated  injections  cause  a  fall  of  pressure  due  to  fatigue  of 
the  vasomotor  centre  and  the  heart.  The  action  of  moderate  doses 
upon  the  peripheral  vessels  is  more  marked  than  in  the  case  of 
barium,  and  upon  the  splanchnic  vessels,  more  marked  than 
adrenalin.^ 

Prolonged  application  of  the  x-rays  to  the  adrenals  of  dogs  pro- 
duces well-marked  structural  degenerative  changes  in  the  glands.^ 
Zimmern  and  jCottenot^  obtained  a  prolonged  clinical  fall  of  pressure 
(20-80  mm.),  associated  with  subjective  improvement,  in  sixteen 
cases  of  chronic  hypertension.  Quadrone  reports  somewhat  similar 
results,  but  Groedel  was  unable  to  obtain  any  reduction  in  cases 
of  hypertension  by  this  means.*  Sergent  and  Cottenot^  noted  a 
pressure  reduction  of  from  40  to  50  mm.  in  hypertension  without 
urinary  abnormalities.  Patients  with  albuminuria  and  those  with 
marked  arteriosclerosis  were  but  little  affected.  There  is  no  rational 
basis  for  this  form  of  treatment.    The  evidence  at  hand  is  not  in 


1  Jackson,  D.  E. :  The  Pharmacological  Action  of  Vanadium,  Jour.  Pharm.  and 
Expor.  Therap.,  1912,  iii,  477. 

*  Cottenot,  Mulow  et  Zimmern:  Action  des  vagons  sur  la  corticale  sur  renali, 
Compt.  rend,  hebdom.  des  sciences  Soc.  biol.,  1912,  Ixxiij,  717.  Similar  results  by 
Galansino  and  Decostello. 

'  La  radiotherapie  des  glandes  sur  renales,  ses  resultats,  ses  effects  hypotenseurs. 
Arch,  d'electr.,  1912,  xx,  500. 

*  Groedel,  F.:   Strahlentherapie  II,  1913,  p.  224. 

'  L'irradiation  des  glandes  surrenales  dans  la  therapeutique  de  I'hypertetision 
arterielle.  Bull,  et  mem.  Soc.  M6d.  d.  hop.,  Paris,  1914,  xxxvii,  385. 


SURGICAL   TREATMENT  335 

favor  of  adrenalinemia  as  a  cause  of  chronic  hypertension,  and  too 
prolonged  exposure  may  do  serious  structural  damage  to  the  glands. 

The  usual  result  of  exposure  in  a  radium  emanatorium  is  a  fall 
of  the  systolic  blood-pressure  amounting  to  20  to  25  mm.  Hg. 
Together  with  this  there  generally  occurs  a  decrease  in  cardiac 
work  and  a  lowering  of  the  diastolic  pressure.  These  changes  are 
apparently  due  to  vascular  dilatation.^ 

Surgical  Treatment. — Renal  decapsulation  has  been  performed  in 
some  cases  of  chronic  nephritis.  Goodman  reports  such  a  case 
in  which  both  the  systolic  and  the  diastolic  pressures  were  very 
definitely  reduced  for  about  two  weeks  following  decapsulation, 
although  the  patient  ultimately  died.^ 

1  Loewy  and  Plesch,  quoted  by  Rowntree  and  Baetjer:  Radium  in  Internal  Medi- 
cine, Jour.  Am.  Med.  Assn.,   1913,  Ixi,   1438. 

2  Goodman,  E.  H. :  Effect  on  Blood-pressxu"e  of  Decapsulation  of  the  Kidney, 
New  York  Med.  Jour.,  October  3,  1914. 


CHAPTER  XIV. 

EFFECTS  OF  DRUGS  AND  GLANDULAR  EXTRACTS 

ON  BLOOD-PRESSURE  (ARRANGED 

ALPHABETICALLY). 

Aconite. — The  effect  of  aconitin  upon  the  mammahan  heart 
may  be  divided  into  two  phases:  (1)  It  produces  slowing  of  the 
rate  with  a  weakening  of  contraction.  The  pulse  rate  may  (experi- 
mentally) be  reduced  one-half  and  blood-pressure  will  fall  propor- 
tionately. These  phenomena  are  due  to  central  stimulation  of 
the  pneumogastric  nerve.  (2)  If  the  administration  of  the  drug  is 
pushed  still  further,  tachycardia  and  arrhythmia  appear,  apparently 
as  a  result  of  direct  action  upon  the  myocardium. 

Aconite  has  been  used  for  the  reduction  of  arterial  hypertension, 
but  its  use  has  not  been  satisfactory.  The  tincture  which  is  marketed 
without  physiological  standardization  varies  greatly  in  potency, 
and  in  the  doses  usually  employed  is  often  inert.  Robinson's^ 
investigations  indicate  that  in  maximal  dosage  aconite  increased 
ventricular  irritability. 

Alcohol. — There  is  much  difference  of  opinion  as  to  the  clinical 
effects  of  alcohol  on  the  circulation,  and  equally  discordant  findings 
have  resulted  from  its  employment  experimentally.  Most  of  the 
evidence  shows  that  alcohol  is  only  a  momentary  cardiac  stimulant 
which  acts  reflexly  through  its  irritation  of  the  mouth,  esophagus, 
and  stomach.  Its  main  effect  is  vasodilation,  and  if  pushed,  nervous 
and  muscular  cardiac  debility.  If,  therefore,  temporary  stimula- 
tion is  desired  it  should  be  given  in  concentrated  form;  if  vascular 
relaxation,  diluted.  Although  it  may  briefly  raise  the  systolic 
pressure  it  raises  the  diastolic  pressure  even  more,  and  thus  lowers 
the  pulse-pressure.2  In  chilliness  due  to  peripheral  vasoconstric- 
tion it  does  good,  but  if  the  patient  be  cold  as  the  result  of  collapse, 
with  a  low  blood-pressure,  it  is  directly  contra-indicated.  It  may 
act  in  part  as  a  food  by  sparing  the  proteids  or  assist  in  prevefiting 

1  An  Investigation  of  the  Potency  of  Tincture  of  Aconite,  Arch.  Int.  Med.,  1915, 
XV,  Part  I,  645. 

2  Lieb,  C.  C:  Reflex  Effects  of  Alcohol  on  the  Circulation,  Jour.  Am.  Med.  Assn., 
1915,  Ixiv.  898. 


ATROPIN  337 

acidosis,  but  in  the  vascular  failure  of  infectious  disease  or  in 
surgical  shock  it  is  harmful.  It  is  irritant  to  the  kidneys  and  delays 
the  elimination  of  certain  substances  (uric  acid,  etc.).  Both  clinical 
and  experimental  evidence  are  against  its  use  as  a  stimulant  in 
conditions  of  low  blood-pressure. 

It  produces  an  unstable  vascular  tonus.  Luzzato,  on  admin- 
istering 30  to  50  gm.  of  alcohol  to  students,  found  no  constant 
relation  between  psychic  phenomena,  pulse  or  respiration  and 
blood-pressure.^  Sphygmobolometric  studies  in  fever  cases  gener- 
ally show  a  diminished  amplitude,  a  lowered  pressure,  and  decrease 
in  cardiac  work.^  The  onset  of  drunkenness  is  associated  with  a 
fall  of  the  systolic  and  the  pulse-pressure,  together  with  an  increased 
pulse  rate.^ 

The  syndrome  of  cardiac  dilatation  with  hypertension  which  is 
seen  in  excessive  beer  drinkers  is  in  part  due  to  the  alcohol,  in  part 
to  the  increased  volume  of  the  blood.  For  obvious  reasons  alcohol 
should  be  taken  sparingly  if  at  all  in  cases  of  nephritic  hypertension. 

Alkalies. — This  class  of  drugs  may  indirectly  assist  in  lowering 
tension  "by  counteracting  acid  irritants,  by  combating  dyspeptic 
tendencies  or  by  their  diuretic  effect. 

Ammonium. — Ammonium  in  the  form  of  the  aromatic  spirit  is 
a  promptly  acting  though  temporary  cardiac  stimulant.  It  is 
useful  in  transient  cardiac  and  vasomotor  weakness,  and  extremely 
valuable  in  the  relief  of  gaseous  gastric  distention  in  arteriosclerotic 
cases  with  precordial  oppression.  The  following  formula  has  often 
proved  most  satisfactory: 

I^ — Spt.  ammonii  aromat TTlxxx  (2.0) 

Spt.  chloroformi        ....  ITlxv  (1.0) 

Spt.  lavenduljE TTlxxx  (2.0) 

Aq.  menth.  piperitae ad  f  3ij  (8.0) 

To  this  prescription  spirit  of  glonoin  may  sometimes  be  advan- 
tageously added. 

Atropin.— Atropin  increases  the  pulse  rate  by  depression  of  the 
peripheral  ends  of  the  vagus  nerve.  It  has  thus  in  part  an  antago- 
nistic action  to  digitalis.  Experimentally  it  increases  blood-pressure 
by  a  slight  stimulation  of  the  vasoconstrictor  centre  and  an  increased 
pulse  rate.     Clinically,  pressor   effects   are  rarely    demonstrable, 

1  Luzzato:    Acad,  dei  Fisiocritici  di  Siena,  January  31,  1909. 

'  Dennig,  Hindelang,  and  Griinbaum:  Ueber  d.  Einfluss  des  alkohols  auf  d.  Blut- 
druck  u.  d.  Herzarbeit  in  path.  Zustanden  namentlich  beim  Fieber,  Deutsch.  Arch, 
f.  kUn.  Med.,  1909,  xcvi,  153. 

3  Holzmann:  Blutdruck  bei  Alkoholberauschten,  Arch.  f.  Psychiatrie,  1909,  xiv,  92. 
22 


338  EFFECTS  OF  DRUGS  ON  BLOOD-PRESSURE 

although  it  is  a  valuable  remedy  in  the  wet,  clammy  stage  of  vascu- 
lar collapse,  in  pulmonary  edema  (in  association  with  morphin), 
and  in  the  treatment  of  hyperchlorhydria,  which  is  a  common 
symptom  in  cases  of  arterial  hypertension.  The  following  formula 
has  often  been  prescribed  with  benefit  for  the  last-named  condition: 

^ — Ext.  belladonnjE gr.  r  2 

Pulv.  rhei gr.  5 

Magnesii  ustse gr.  iv 

Carbo  ligni gr.  j. 

To  be  taken  in  capsules  or  as  a  powder  after  meals. 

Caffein. — Caffein  stimulates  the  entire  nervous  system,  and 
may  therefore  be  used  if  the  circulatory  disturbance  is  central  in 
origin. 

Experimental  Data. — Caffein  injections  in  dogs  cause  a  short  rise 
(five  seconds)  followed  by  a  fall  of  pressure  (fifteen  seconds) .  The 
larger  the  dose  the  greater  the  subsequent  fall.^  Caffein  raises 
blood-pressure  which  has  been  depressed  by  alcohol,  chloral,  and 
infections  even  in  late  stages.  Moderate  dosage  is  more  effective 
than  large  doses,  the  latter  may  induce  arrhythmia,  palpitation, 
insomnia  and  gastric  disturbances.  Caffein  increases  splanchnic 
tone.  The  experimental  data  are  for  the  most  part  inapplicable 
to  clinical  work  on  account  of  the  large  dosage  employed. 

The  rise  of  pressure  produced  by  caffein,  which  is  never  great, 
is  due  in  part  to  increased  splanchnic  tonus  and  in  the  latter  stages 
also  to  the  increased  pulse  rate.  Owing  to  splanchnic  constriction 
the  right  heart  receives  more  blood,  and  as  the  result  of  peripheral 
dilatation  the  outflow  from  the  left  heart  is  increased.  Furthermore, 
dilatation  of  the  coronary  arteries  leads  to  better  cardiac  nutrition^ 
and  more  forcible  contraction.  The  pulse  rate  is  usually  not  much 
affected,  but  retardation  is  more  frequent  than  acceleration.^ 
Large  doses  cause  a  fall  of  blood-pressure  with  diminished  cardiac 
tonus. 

Caffein  exerts  a  selective  action  on  the  vessels  of  the  kidney. 
A  primary  constriction  is  followed  by  a  marked  secondary  dilatation 
wliich,  with  a  constant  arterial  pressure,  causes  a  marked  increase 
in  local  blood  flow  and  of  urinary  secretion.  Caffein  is  capable 
of  increasing  urinary  secretion  even  if  a  volumetric  increase  is 
prevented,  probably  as  the  result  of  increased  blood  flow.* 

1  Pilcher,  J.  D.:  Jour.  Phar.  and  Exp.  Therap.,  1912,  iii,  609, 

*  Meyer  and  Gottlieb:    Die  Experim.  Pharmakologie,  Vienna,  1910,  p.  263. 

•Wood,  H.  C,  Jr.:    Therap.  Gaz.,  January  15,  1912. 

<  Weber:   Arch.  f.  exp.  Path.  u.  Phar.,  1906,  liv,  1. 


THE  DIGITALIS  GROUP  339 

In  two  normal  individuals  during  rest,  caffein  appeared  to  increase 
the  total  blood  flow  and  volume  per  beat.^ 

Clinical  Bala. — ^The  effect  of  caffein  is  more  prompt  and  more 
brief  than  that  of  the  digitalis  group,  but  it  lacks  the  tonic  effect 
of  the  latter.  It  may  be  administered  either  in  its  pure  form  or  as 
the  citrate  or  in  the  form  of  tea  or  coffee.  Therapeutically  it  rarely 
produces  a  demonstrable  rise  of  blood-pressure.  It  is  useful  as  a 
cardiovascular  and  renal  stimulant  in  both  acute  and  chronic  dis- 
ease, but  to  be  effectual  must  often  be  given  in  larger  dosage  than 
is  customary.  Better  results  are  obtained  by  using  theobromin- 
salicylate,  since  the  untoward  effects  of  caffein  are  avoided.^ 

Camphor. — Camphor  is  said  to  raise  blood-pressure  by  medullary 
and  cardiac  stimulation.  The  drug  has  long  been  used,  especially 
as  a  cardiac  stimulant.  Both  clinically  and  experimentally  it 
produces  at  least  a  temporary  improvement  of  the  pulse  even  in 
the  agonal  stage  of  infectious  disease.  It  is  normally  neutralized 
in  the  body  and  thus  rendered  inert  by  glycuronic  acid,  and  may 
produce  toxic  symptoms  in  cases  in  which  the  latter  substance  is 
diminished  (starvation,  cachexia,  sepsis,  eclampsia,  CO2  poisoning). 
Nothing  short  of  a  toxic  dose  has  any  effect  on  blood-pressure 
in  normal  animals  because  compensatory  vascular  changes  readily 
neutralize  abnormal  stimuli.  Head  and  Brooks'*  failed  to  get  any 
definite  circulatory  results  either  clinically  or  experimentally. 
When  applied  to  the  isolated  dog's  heart  no  distinct  or  constant 
stimulation  is  observed"*  nor  does  the  therapeutic  dose  have  any 
effect  upon  the  vasomotor  centre.^  The  administration  of  the  drug 
in  emulsion  has  been  commended  as  being  a  more  certain  and 
satisfactory  method  of  obtaining  the  physiological  effects.^ 

The  Digitalis  Group. — Based  purely  upon  experimental  evidence 
digitalis  should  be  the  ideal  drug  to  employ  in  case  of  arterial 
hypotension,  since  it  increases  the  force  of  cardiac  contraction  as 
well  as  vascular  tonus.  Clinical  data,  however,  show  that  in 
therapeutic  dose  digitalis  often  does  not  increase  blood-pressure; 
in  fact,  it  frequently  lowers  it,  especially  in  heart  diseases  with  high- 
pressure  stasis  and  in  hypertension  due  to  toxic  renal  retention. 
If  prompt  action  is  desired  it  should  be  given  intravenously  (digi- 
folin,  digipuratum,  strophanthin,  ouabain).     If  given  by  mouth 

1  Means  and  Newburgh:    Tr.  Assn.  Am.  Phys.,  1915.  xxx,  51. 

*  Taylor,  I.:    Clinical  Studies  in  Caffein,  Arch.  Int.  Med.,  1914,  xiv,  769. 
» Am.  Jour.  Med.  Sc,  1913,  cxlv,  238  (bibliography). 

<  Plant,  O.  H.:   Jour.  Phar.  and  Exp.  Therap.,  1914,  v,  571. 

*  Pilcher  and  Sollmann:    Jour.  Exp.  Med.,  xxi,  330. 
8  Doctoriwitch:    Therap.  d.  Gegenw.,  xlvii,  343. 


340  EFFECTS  OF  DRUGS  ON  BLOOD-PRESSURE 

its  effects  are  not  evident  for  twenty-four  hours  or  more.  There' 
has  been  much  discussion  regarding  its  effect  upon  the  toxic  heart 
of  fevers,  many  authorities  maintaining  its  uselessness  in  pneumonia, 
typhoid  fever,  etc.  Important  evidence  of  its  activity  has  been 
furnished  by  Cohn,^  who  showed  electrocardiographically,  although 
the  heart-rate  remained  unaffected,  other  digitalis  effects — pro- 
longation of  the  a-c  interval  and  inversion  of  the  T-wave  were 
produced  in  hearts  with  a  normal  sinus  rhythm,  while  the  same 
rate  changes  were  noted  in  cases  of  auricular  fibrillation  or  flutter 
as  occurred  in  afebrile  cases.  H.  C.  Wood,  Jr.,  believes  that  although 
medicinal  doses  of  digitalis  do  not  raise  blood-pressure,  yet  they 
probably  do  have  some  slight  effect  on  the  vasomotor  system.  This 
view  is  based  upon  the  fact  that:  (1)  if  slowing  of  the  pulse  is 
abolished  by  atropin,  strophanthus  causes  a  marked  increase  of 
pressure  in  normal  man;  (2)  the  diuretic  effects  of  the  dtug, 
although  independent  of  systemic  pressure  changes,  may  result 
from  a  relative  splanchnic  contraction  at  a  time  when  the  renal 
vessels  are  dilated  by  the  drug.^ 

Marvin,^  in  experiments  on  healthy  students,  found  an  increase 
in  blood-pressure  (average  13  mm.)  which  reached  its  maximum  in 
five  hours  and  gradually  returned  to  the  normal  in  fifty  hours. 

Digitalis  is  the  most  useful  drug  in  cases  of  hypertension  when 
the  heart  is  beginning  to  fail.  In  such  cases  its  use  need  not  be  feared 
on  account  of  increasing  vascular  pressure.  This  effect  is  generally 
not  in  evidence,  whereas  it  often  lowers  tension,  especially  the 
diastolic  pressure,  by  securing  better  elimination  and  a  more  efficient 
circulation.  In  auricular  fibrillation  digitalis  does  raise  the  average 
systolic  pressure  (see  page  251).  The  action  of  digitalis  and  digi- 
toxin  is  more  prolonged  than  that  of  strophanthus  and  digitalin.'' 

In  nephritic  hypertension,  as  the  renal  lesion  progresses,  pressure 
continues  to  rise,  and  unless  some  other  lethal  termination  occurs, 
either  the  heart  or  the  vascular  system  must  in  time  give  way. 

Heart  failure  may  manifest  itself  by  (1)  a  fall  of  blood-pressure, 
edema,  dyspnea,  oliguria,  and  cardiac  dilatation,  or  (2)  high-pressure 
stasis,  a  condition  in  which  blood-pressure  remains  high  or  even 
rises  (increased  toxemia)  and  is  associated  with  dyspnea,  cardiac 
arrhythmia  and  visceral  stasis. 

In  both  these  conditions  digitalis  is  indicated,  but  especially  if 
the  systolic  and  diastolic  pressures  are  low,  and  the  pulse-pressure 

•  Cohn,  A.  E.:    Digitalis  in  Pneumonia,  Jour.  Exper.  Med.,  1917,  xxv,  65. 

2  Wood,  H.  C,  Jr.:   Newer  Ideas  Concerning  Digitalis,  Therap.  Gaz.,  June  15,  1915. 
'  Arch.  Int.  Med.,  1913,  xi,  418. 

*  Hatcher,  R.  A.:  The  Persistence  of  Action  of  the  Digitalins,  Arch.  Int.  Med., 
1912,  X.  268. 


THE  DIGITALIS  GROUP  341 

small.  In  these  cases  digitalis  often  increases  the  pulse-pressure 
and  improvement  occurs.  Under  its  administration  renal  elimina- 
tion is  increased  and,  in  high-pressure  cases,  an  actual  lowering 
of  arterial  pressure  is  not  infrequently  seen.  The  final  break  can 
often  be  delayed  by  appropriate  stimulation,  for  which  purpose 
digitalis  is  by  far  the  most  satisfactory  remedy. 

Digitalis  exerts  its  effects  on  the  kidney  indirectly  by  its  local 
effect  on  blood  flow;  it  also  produces  a  direct  local  dilatation  of 
the  renal  vessels.  Its  chief  use  in  renal  disease  consists  in  its 
improvement  of  the  local  circulation  by  its  effect  upon  the  heart. 
Experimentally,  ligation  of  the  renal  vein  causes  suppression  of 
urine  as  well  as  ligation  of  the  renal  artery,  showing  that  secretion 
is  a  question  of  blood  flow,  not  merely  of  blood-pressure,  and  digi- 
talis not  only  increases  arterial  flow  but  diminishes  venous  stasis. 
When  too  freely  administered,  digitalis  may  cause  centric  vomiting. 
It  has  long  been  taught  that  emetics  should  not  be  given  to  arterio- 
sclerotics lest  the  increased  blood-pressure  produced  cause  vascular 
rupture. 

From  recent  researches*  it  appears  that  vomiting  is  generally 
associated  with  a  sudden  and  very  great  fall  of  pressure,  due  to 
cardiac  inhibition  but  always  associated  with  very  great  pressure 
variations.  Great  and  sudden  pressure  oscillations  may  cause 
vascular  damage  at  actual  pressure  heights  which,  had  the  rise  been 
gradual,  would  have  been  without  serious  effect.  It  is  just  as 
important,  therefore,  to  avoid  emesis  in  arteriosclerosis  as  was 
early  taught,  though  for  a  somewhat  different  reason. 

Failing  cardiac  compensation  is  frequently  associated  with  an 
increase  of  venous  blood-pressure  to  or  above  20  cm.  Such  a  rise 
is  therefore  prognostically  unfavorable,  especially  if  it  continues  or 
increases  despite  the  administration  of  digitalis  or  its  congeners.^ 

Strophanthns  and  squills  act  in  the  same  manner,  but  are  less 
satisfactory-  than  digitalis  because  of  the  variability  of  absorption 
of  the  former  and  because  of  the  variability  of  activity  and  irritant 
(gastro-intestinal)  qualities  of  the  latter.  In  therapeutic  dose 
neither  strophanthin  nor  digalen  affect  the  voliune  of  the  arm  nor 
its  normal  reaction  to  the  application  of  cold,  although  injections 
of  these  substances  are  said  to  affect  the  tonus  of  the  larger  arteries.^ 

1  Brooks,  C,  and  Luckhardt,  A.  B.:  Blood-pressure  during  Vomiting,  Am.  Jour. 
Physiol.,  1915,  xxxvi,  104. 

''Clark,  A.  H.:  The  Diagnostic  and  Prognostic  Significance  of  Venous  Pressure 
Observations  in  Cardiac  Disease,  Arch.  Int.  Med.,  1915,  xvi,  587. 

'Hewlett,  A.  W.:  The  Circulation  in  the  Arm  of  Man,  Am.  Jour.  Med.  Sc, 
1913,  cxlv,  656. 


342  EFFECTS  OF  DRUGS  ON  BLOOD-PRESSURE 

Depressants. — Chloral,  the  coal-tar  group,  bromides,  etc.,  will 
in  sufficient  dose  lower  blood-pressure.  They  should,  however, 
never  be  used  for  this  purpose,  although  they  may  on  occasion  be 
useful  in  relieving  pain  or  promoting  sleep.  Chloral  may  produce 
degenerative  changes  in  heart  and  liver  similar  to  those  following 
the  administration  of  chloroform. 

Emetin. — This  drug  is  sometimes  administered  intravenously. 
This  is  not  a  safe  procedure,  since  the  drug  is  a  cardiac  depressant. 
If  this  method  of  administration  must  be  employed,  coincident 
blood-pressure  readings  are  desirable  with  a  view  of  detecting 
evidences  of  circulatory  failure  (R.  L.  Levy). 

Epinephrin. — (See  under  Physiology,  page  35.)  Epinephrin  may 
be  administered  by  mouth  without  any  demonstrable  cardio- 
vascular action.  Prolonged  use  in  this  way  leads  to  dyspepsia 
associated  with  colicky  pains.  Large  doses  given  to  rabbits  produce 
arterial  degeneration  without  increasing  blood-pressure. 

Exyerhrnental  Data. — Epinephrin  produces  upon  the  cardio- 
vascular system  the  same  effect  as  would  electric  stimulation  of 
the  sympathetic — a  marked  rise  of  blood-pressure  due  to  vaso- 
constriction and  increased  cardiac  action  (increased  systolic  output). 
This  rise  is  of  brief  duration,  due  to  fatigue.  Venous  pressure 
rises  slightly.  The  different  arteries  are  contracted  in  proportion 
to  their  sympathetic  innervation.  The  coronary  arteries  are  said 
to  be  unaffected  (Schafer),  owing  to  the  absence  of  sympathetic 
fibers.  In  experimental  animals  epinephrin  causes  coronary  dila- 
tation, but  in  man  (isolated  arteries)  and  in  monkey  (perfused 
hearts)  it  causes  coronary  constriction,  presumably  because  in  the 
latter  species  the  arteries  are  supplied  with  constrictor  nerves 
of  true  sympathetic  (thoracicolumbar)  origin.^  Epinephrin  dimin- 
ishes the  pulse  rate  through  vagus  stimulation.^  In  small  dose  it 
increases  the  rapidity  of  the  pulmonary  circulation;  in  excessive 
dose  it  may  cause  pulmonary  edema  in  men  (Bennett)  as  it  does  in 
animals.  Large  doses  and  vagus  stimulation  diminish  it.  Apnea 
during  artificial  respiration  has  no  effect  on  pulmonary  circulation.'' 
The  intraspinal  injection  of  adrenalin  causes  a  slower  but  more 
prolonged  rise  of  pressure  (40  mm.  for  half  an  hour  or  longer), 

'  Barbour  and  Prince :  Influence  of  Epinephrin  on  the  Coronary  Circulation  of  the 
Monkey,  Jour.  Exp.  Med.,  1915,  xxi,  300. 

*  Meek  and  Eyster:  Effect  of  Epinephrin  on  the  Heart  Rate,  Am.  Jour.  Physiol., 
1915,  xxxviii.  No.  1. 

'  Langlois,  P.,  and  Desbouis,  G. :  Sur  la  vitesse  de  la  circulation  pulmonaire, 
Adi6naline,  Digitaline,  Asphyxie.  Respiration  Artificielle,  M6m.  2,  Jour.  d6  physiol. 
et  de  Pathol,  gen.,  1912,  xiv,  S.  1113-1123. 


EPINEPHRIN  343 

although  occasionally  preceded  by  a  primary  fall  (9  to  50  mm. 
for  a  half  to  four  minutes).^ 

In  using  intraspinal  injections  care  must  be  taken  to  avoid 
sudden  increase  of  pressure.  It  is  safer  to  allow  inflow  only  by  the 
force  of  gravity.  Too  high  an  intraspinal  pressure  is  first  mani- 
fested by  cessation  of  respiration,  soon  followed  by  cardiac  inhibi- 
tion and  an  enormous  fall  of  blood-pressure.  To  combat  cardiac 
failure  under  these  circumstances  atropin  is  the  most  useful  drug, 
whereas  cocain  is  the  best  respiratory  stimulant.  Since  the  fall 
of  pressure  is  not  due  to  vasomotor  failure,  epinephrin  is  not 
indicated.  The  lowering  of  the  intraspinal  pressure  after  symptoms 
have  arisen  is  unproductive  of  benefit.  It  has  been  suggested  that 
a  local  hypodermic  prophylactic  injection  of  cocain  and  atropin  be 
given  at  the  site  of  the  spinal  injection,  especially  if  the  patient 
be  under  the  effects  of  chloroform,  since  it  not  only  minimizes  the 
danger  of  sudden  death  but  allows  a  larger  injection  to  be  given 
(Carter)  .^  (See  page  410.)  Experimentally,  epinephrin  has  by  some 
investigators  been  found  to  be  beneficial  in  hemorrhage,  chloroform 
poisoning,  pneumococcus  septicemia,  and  diphtheria  intoxication. 
On  the  other  hand,  Gottleib  has  shown  that  in  rabbits  receiving 
diphtheria  toxin  daily  until  cardiovascular  symptoms  appear,  the 
injection  of  adrenalin  only  produces  a  brief  and  deceptive  rise  of 
arterial  tension  which  soon  leads  to  a  fatal  termination.^ 

Epinephrin  is  very  rapidly  effective  in  its  pressor  effect  when 
intratracheally  injected.  Absorption  appears  to  occur  by  the  capil- 
lary route  into  the  pulmonary  veins  and  is  quickly  manifest,  even 
in  pulmonary  edema,  although  absorption  is  in  this  condition 
greatly  handicapped.* 

Clinical  Data. — A  marked  fall  of  blood-pressure  due  to  vaso- 
motor depression  without  cardiac  weakness  is  the  chief  indication 
of  the  use  of  epinephrin.  Thus  in  shock,  chloral  poisoning,  and 
collapse  occurring  in  ether  or  chloroform  narcosis  it  is  decidedly 
useful.  It  should  be  administered  intravenously  in  5-  to  10-minim 
doses  (1  to  1000  solution)  or,  better  still,  in  the  proportions  of  1  to 
50,000  as  a  continuous  saline  infusion.  If  a  slower  and  more  pro- 
longed action  is  desired  it  may  be  given  subcutaneously,  in  which 
event  its  effects  are  usually  manifest  in  from  five  to  fifteen  minutes. 

*  Auer  and  Meltzer:  Proc.  Soc.  Exp.  Biol,  and  Med.,  1912,  ix,  79.  (Experiments 
on  deeply  narcotized  apes.) 

*  The  Effect  of  Intraspinal  Injections  of  Ringer's  Solution  in  Different  Amounts 
under  Varying  Pressures,  Arch.  Int.  Med.,  1912,  x,  425. 

'  Gottleib:    Arch.  f.  exp.  Pharm.,  xxxviii  and  xliii. 

^  Auer,  J.,  and  Gates,  F.  L. :  The  Absorption  of  Adrenalin  after  Intratrachea ' 
Injection,  Joiu.  Exper.  Med.,  1916,  xxiii,  757. 


344  EFFECTS  OF  DRUGS  ON  BLOOD-PRESSURE 

One  naturally  thinks  of  epinephrin  in  the  vasomotor  pareses 
of  infections,  but  its  use  is  under  these  circumstances  disappointing. 
The  condition  here  is  not  a  sudden  emergency  with  a  good  cardiac 
muscle,  but  a  gradual  failure  of  vasomotor  and  often  cardiac 
strength.  We  must  not  forget  that  if  the  heart  weakness  is  present 
a  sudden  increase  of  arterial  pressure  may  be  more  of  a  load  than 
the  staggering  organ  can  bear.  The  best  and  most  lasting  effects 
are  obtained  by  slow  intravenous  administration  in  dilution  with 
normal  salt  solution.  Epinephrin  has  proved  useful  in  vasomotor 
failure  due  to  diphtheria,  pneumonia,  plague,  peritonitis,  and  in 
surgical  shock. 

Hypodermic  epinephrin  injections  are  variable  in  their  effects. 
They  do  not  always  increase  blood-pressure,  but  when  they  do  so 
the  rise  generally  lasts  about  one  hour.  The  systolic  phase  is 
influenced  more  than  the  diastolic,  indeed  the  latter  may  actually 
fall.  Glycosuria  may  occur,  but  this  bears  no  constant  relation  to 
pressure  changes.  A  preliminary  dose  of  atropin  may  increase  the 
reaction  even  without  increasing  the  heart  rate.  Marked  reactions, 
both  objective  and  subjective,  are  often  produced  in  cases  of  essen- 
tial hypotension,  whereas  low  pressure  due  to  diarrhea  and  cachexia 
is  but  little  influenced  by  epinephrin.  In  arterial  hypertension 
marked  reactions  are  sometimes  obtained  and  caution  must  be 
observed.  Epinephrin  increases  the  demarcation  of  the  sound 
phases  as  heard  in  the  auscultatory  estimation  of  blood-pressure 
(Clough). 

Fresh  preparations  of  epinephrin  must  be  employed,  since  old 
preparations  loose  their  constrictor  but  not  their  depressor  effect, 
and  hence  an  intravenous  or  intramuscular  dose  may  actually 
lower  blood-pressure. 

Ergot. — Experimental  Data. — "  The  action  of  ergot  may  be  shortly 
defined  as  a  primary  stimulation  followed  by  paralysis  (if  given  in 
large  dose)  of  the  motor  terminations  of  the  sympathetic  nerve, 
which  arises  from  the  thoracic  and  lumbar  spinal  cord.  The  point 
at  which  ergot  acts  is  thus  analogous  to  that  affected  by  adrenalin, 
but  the  range  of  ergot  is  more  limited,  for  adrenalin  affects  not 
only  the  motor  or  positive  nerve  ends  but  also  the  inhibitory  or 
negative  fibers.  In  addition  the  effects  of  ergot  are  not  so  transitory 
as  those  of  adrenalin,  while,  on  the  other  hand,  the  latter  does 
not  exercise  any  subsequent  paralyzing  action  of  consequence" 
(Cushny). 

An  intravenous  injection  of  ergotoxin  is  followed  by  a  prompt, 
abrupt   rise   of  hhod-pressure;    this   occurs   after  section   of  the 


HYDRASTIS  345 

splanchnic  nerves,  showing  it  to  be  a  peripheral  effect.  The  vessels 
of  the  abdomen  and  the  extremities  become  contracted.  The  pulse 
rate  is  often  increased  at  first,  then  diminished  partly  from  the  vagus 
stimulation  from  high  blood-pressure  and  partly  from  direct  action 
upon  the  heart  muscle.  The  rise  of  pressure  varies  greatly  in 
different  species  (Cushny).  The  administration  of  a  large  dose 
produces  a  secondary  fall  of  arterial  tension  due  to  paralysis  of 
the  sympathetic  fibers,  which  even  epinephrin  fails  to  overcome.^ 

Para-oxyphenylethylamin  (isolated  from  ergot) . — Experimentally 
this  substance  causes  a  rise  of  pressure  due  to  capillary  contraction 
associated  with  bradycardia  and  an  increased  pulse  amplitude  and 
diminution  of  blood  in  the  veins.  Its  action  is  transient  and 
followed  by  normal  readings.^ 

Clinical  Data. — Ergot  is  of  very  little  if  any  use  as  a  drug  with 
which  to  restore  vasomotor  tone,  its  effects  being  very  fugacious. 
Its  action  upon  the  pulmonary  circulation  has  been  discussed  under 
Hemoptysis  (see  page  226).  It  is  highly  important  that  all  ergot 
preparations  used  in  medicine  be  physiologically  standardized, 
not  only  because  some  preparations  are  inert  but  also  because  it 
has  been  shown  that  ergot  sometimes  contains  small  amounts 
of  acetylcholin  which  has  been  pronounced  to  be  the  most  powerful 
circulatory  depressant  known,  as  small  an  amount  as  one-millionth 
part  of  a  milligram  causing  a  fall  of  blood-pressure  in  rabbits.' 

Hydrastis. — Although  rarely  employed  in  medicine,  hydrastis  is 
occasionally  recommended  in  the  treatment  of  hemoptysis  owing 
to  a  supposed  vasoconstrictor  action.  Experimental  evidence,  how- 
ever, indicates  that  it  has  no  such  effect.  W.  W.  Williams,^  from 
a  careful  experimental  research,  comes  to  the  following  conclusions: 

The  most  constant  and  conspicuous  effect  of  the  intravenous 
injection  of  hydrastis  is  a  prompt  fall  of  blood-pressure.  With 
small  doses  the  pressure  promptly  returns  to  normal,  and  there 
may  be  a  slight  rise  above  normal.  With  larger  doses  from  (0.07  c.c. 
to  1  c.c.  per  kilogram  of  body  weight)  there  is  only  partial  recovery 
from  the  fall  of  blood-pressure,  or  it  may  remain  low.  The  pressure 
phenomena  are  attributable  to  depression  of  the  cardiac  muscle, 
causing  the  fall,  and  to  stimulation  of  the  muscle,  causing  the  rise. 
Very  large  doses  depress  and  paralyze  the  vagus  and  vasomotor 

>  Dale:    Jour.  Physiol.,  1906,  xxxiv,  163. 

*  Bickel,  A.,  and  Pawlow,  M.:  Untersuchungen  z.  pharm.  Wirkung  des  p.  Oxy- 
phenylaethylamins,  Biochem.  Ztschr.,  1912,  xlvii,  345. 

'  Editorial,  Jour.  Am.  Med.  Assn.,  1914,  Ixiii,  2136.     Discussion  and  literature. 

*  The  Effects  of  Hydrastis  and  its  Alkaloids  on  Blood-pressure,  Jour.  .\m.  Med. 
Assn.,  January  4,  1908,  p.  26  (bibliography). 


346  EFFECTS  OF  DRUGS  ON  BLOOD-PRESSURE 

system;  otherwise  there  is  no  evidence  deduced  from  the  myo- 
cardiograms  and  oncometer  that  the  vasomotor  system  has  any 
important  part  in  the  blood-pressure  changes. 

The  two  principal  alkaloids  of  hydrastis,  hydrastin  and  herherin, 
cause  qualitatively  the  same  blood-pressure  changes,  although 
herherin  is  the  more  active  and  is  responsible  for  about  85  per  cent, 
of  the  effect  of  hydrastis — hydrastin  causing  the  remaining  15  per 
cent.  Hydrastis  given  by  mouth  or  hypodermically  causes  no 
change  in  the  blood-pressure,  heart  rate,  or  respiration. 

Ilydrastinin,  an  artificial  alkaloid,  derived  from  hydrastin,  causes 
a  rise  of  blood-pressure  above  normal,  which  is  usually  preceded  by 
a  slight  fall  when  injected  intravenously.  The  rise  is  well  sustained 
and  is  principally  caused  by  stimulation  of  the  cardiac  muscle. 

"The  results  of  this  investigation  do  not  support  the  clinical 
theories  concerning  hydrastis.  It  is  possible  that  conditions  in 
man  and  in  disease  may  modify  the  actions  observed  by  me,  but 
this  is  rather  improbable.  At  least  the  uniform  contradiction  of 
the  experimental  results  and  clinical  opinions  demands  that  the 
latter  be  examined  critically  before  they  are  accepted." 

Hormonal. — This  drug  has  been  used  as  a  remedy  against  intes- 
tinal atony  and  paralysis.  Mohr  states  that  bis  experimental 
research  on  hormonal  has  established  beyond  question  its  pro- 
nounced effect  in  reducing  hlood-pressnre  even  with  doses  propor- 
tionately far  below  those  used  in  the  clinic  to  date.  He  had  an 
experience  with  a  threatened  collapse  in  a  man,  aged  twenty-eight 
years,  after  intravenous  injection  of  14  c.c.  of  hormonal,  and  since 
then,  he  says,  four  similar  cases  have  been  reported.  Madlener  has 
recently  reported  the  death  of  a  patient  after  injection  of  20  c.c. 
hormonal  for  paralytic  ileus  following  a  myoma  operation.  Saba- 
towski's  research  on  dogs  has  further  confirmed  the  sudden  pro- 
nounced drop  in  the  blood-pressure  after  intravenous  injection  of 
hormonal. 

The  Iodides. — There  is  a  difference  of  opinion  regarding  the  effect 
of  the  iodides  on  blood-pressure.  Certainly  they  are  not  active  vaso- 
dilators in  the  sense  that  the  nitrites  are.  On  the  other  hand,  cases 
are  occasionally  encountered  in  which  a  lowering  of  tension  occurs, 
a  response  which  naturally  suggests  that  the  hypertension  was 
reflexly  due  to  syphilitic  aortitis  or  directly  to  endarteritis.  The 
former  may  exert  an  effect  on  the  depressor  nerve,  the  latter  may 
cause  loss  of  vascular  elasticity  from  cellular  infiltration. 

Experimentally,  potassium  iodide,  if  administered  intravenously 
causes  a  fall  of  blood-pressure,  but  it  has  been  shown  that  this 


THE  NITRITE  GROUP 


347 


effect  is  solely  due  to  tlie  effect  of  the  kation  (potassium)  while 
the  action  of  the  ion  (iodide)  is  actually  one  of  stimulation,  both 
of  heart  and  bloodvessels.^ 

The  absorption  of  iodides  from  the  intestinal  tract  is  rapid  up  to 
a  certain  point,  beyond  which  a  stoppage  occurs  which  apparently 
results  from  some  local  action.  It  is  unaffected  by  blood-pressure 
except  when  this  is  very  low,  when  absorption  is  somewhat  slower.^ 

So  far  as  hypotensive  effects  are  concerned,  the  iodides  may  be 
employed  in  syphilitic  arteritis  and  in  lead  poisoning,  q.  v.  The 
custom  of  giving  small  doses  over  prolonged  periods  of  time  in  other 
varieties  of  hypertension,  while  very  common,  is  probably  useless. 
The  iodides  have  no  direct  effect  upon  blood-pressure. 

Mistletoe  {Viscum  Album). — Mistletoe  has  been  used,  chiefly 
in  Europe,  for  the  purpose  of  lowering  blood-pressure.  Experi- 
mentally (in  a  dog)  intravenous  injection  promptly  and  progres- 
sively lowers  blood-pressure  20  to  30  mm.  Hg.  This  is  associated 
with  acceleration  of  the  pulse,  with  diminished  amplitude,  and 
after  a  stationary  period,  a  gradual  rise  of  pressure  to  the  normal 
level  (one  to  two  hours).  This  action  is  the  result  of  central  depres- 
sion of  the  vasomotor  centre.^  Mistletoe  has  been  given  in  doses  of 
30  to  60  m.  of  the  fluidextract,  and  as  guipsine,  a  glucoside  which  is 
said  to  represent  the  active  properties  of  the  drug.  This  is  given  in 
pill  form  in  doses  of  5  cgm.,  three  or  four  times  daily.* 


MINUTES 
1       15      30 

HCuns 
.'                                3 

5                                      6 

f 

h 

^ 

=p= 

=- 

\SODIUM  ERYTHROL  MANNITOL 

NITRATE      TETRANITRATE       NITRATE 


Fig.  102. — Diagram  showing  the  comparative  promptness  of  action  and  duration  of 
effect  of  different  blood-pressure-lowering  drugs.     (After  Mathews.) 

The  Nitrite  Group. — The  most  potent,  as  well  as  the  most  mal- 
administered  and  abused  of  the  blood-pressure-lowering  remedies  are 
the  nitrites.    Their  action  is  rapid  and  their  effect  is  for  the  most 


^  Macht,  D.  I.:   Action  of  Potassium  and  Sodium  Iodides  and  of  Iodine  Ion  on  the 
Heart  and  Bloodvessels,  Bull.  Johns  Hopkins  Hosp.,  September,  1914. 

*  Hanzlik,  P.  J.:     Quantitative  Studies  on  the  Gastro-intestinal  Absorption  of 
Dings,  Jour.  Pharm.  and  Exp.  Therap.,  1912,  iii.  No.  4. 

'  Gaulthier,  R.:     Etudes  physiologiques  sur  le  qui,  Arch.  Internat.  d.  pharmaco- 
dynamic, 1910,  Nos.  1  and  2. 

*  Williamson,  O.  K. :     Observations  on  the  Use  of  Guipsin  as  an  Apressor  Remedy 
in  Cases  of  High  Arterial  Blood-pressure,  Practitioner,  May  11,  1911. 


348  EFFECTS  OF  DRUGS  ON  BLOOD-PRESSURE 

part  fugacious.  Furthermore,  a  tolerance  for  this  class  of  drugs  is 
rapidly  established  (Fig.  102).  They  should  therefore  be  given  fre- 
quently and  in  sufficient  dose  to  produce  their  physiological  effect. 
The  typical  action  is  not  only  vasodilatation  but  also  an  increased 
systolic  output  which  occasions  "a  more  rapid  flow.^  The  following 
table  shows  the  effect  of  these  drugs  upon  normal  individuals: 

Average  Blood-pressure  Results  from  Administration  of  Nitroglycerin, 

Sodium  Nitrite,  and  Erythrol  Tetranitrate  to  Normal  Persons. 

(Wallace  and  Ringer.) 


Time  of 
beginning 
action. 
Drug.                                Min. 

Time  of 

maximum 

effect. 

Min. 

Time  of 

duration  of 

action. 

Min. 

Maximum 

extent  of 

action. 

Mm.  Hg. 

Per  cent. 

Amyl  nitrite,  3  minims       .        1 

3 

7 

15 

11 

Nitroglycerin,    I5    minims, 

1  per  cent.  sol.      ...       2 

8 

30 

15 

11 

Sodium  nitrite,  1  gr.      .      .      10 

25 

60 

14 

13 

Erythrol  tetranitrate,  5  gr.     15 

32 

120  to  240 

16 

14 

It  will  be  noted  that  promptness  of  action  and  duration  of  the 
effect  will  tend  to  vary  inversely.  The  therapeutic  effects  are 
obtained  about  as  promptly  when  the  drug  is  given  by  mouth  as 
when  it  is  administered  hypodermically.  The  percentage  of  fall 
is  markedly  uniform,  the  higher  the  initial  presslire  the  greater 
the  drop. 

It  is  important  to  remember  not  only  that  tolerance  to  the  nitrites 
is  often  quickly  established  but  also  that  the  effect  of  different 
members  of  the  nitrite  group  may  vary  in  their  effect  upon  a  given 
individual. 

Physiological  Action. — Different  members  of  the  nitrite  group  of 
drugs  have  an  essentially  similar  action.  Their  effects  vary  only 
in  promptness,  intensity,  and  duration.  The  chief  action  of  the 
nitrites  is  that  of  lowering  blood-pressure  (depression  of  the  nerve 
endings  and  musculature  of  the  arterioles)  and  acceleration  of  the 
pulse  rate,  thus  causing  an  increased  rate  of  blood  flow.  The  veins 
are  also  dilated.  The  vessels  most  affected  are  those  of  the 
splanchnic  system  and  of  the  head.  The  vasomotor  centre  is  not 
depressed  but  as  a  rule  actually  stimulated,^  probably  as  a  result  of 
medullary  anemia.  The  nitrites  are  believed  to  cause  constriction 
of  the  pulmonary  arteries,  since  local  application  causes  a  con- 
traction of  arterial,  strips.'  Such  an  action  would  render  their 
emploj^ment  in  pulmonary  edema  rational. 

'  Cameron  and  Hewlett:   Jour.  Med.  Research,  December,  1906. 
*  Pilcher  and  SoUman:   Jour.  Phar.  and  Exp.  Therap.,  vi,  323. 
'  Macht:  Jour.  Phar.  and  Exp.  Therap.,  ^-i,  13. 


THE  NITRITE  GROUP  349 

Mode  of  Action. — Nitroglycerin  is  represented  by  the  formula: 

CHaONOi! 

I 

CHON02 

I 

CH20N02 

"It  is  probable,  however,  that  in  the  presence  of  water  and 
hydrochloric  acid  in  the  stomach  it  is  decomposed,  and  that  its 
decomposition  products  NO2  and  NO  are  disengaged  in  the  form 
of  brown  vapors  which  are  irritants  and  strong  oxidizers.  These 
ultimately  produce  an  impression  on  the  centripetal  nerve  endings 
in  the  gastric  mucosa,  which  impulse  is  carried  to  the  vasomotor 
centre  and  by  the  centrifugal  nerves  conveyed  from  the  centre 
of  the  vascular  wall,  thereby  causing  the  expansion  of  the  vessels. 
This  dilatation  is  due  either  to  inhibition  of  the  vasoconstrictors 
or  to  stimulation  of  the  vasodilators"  (W.  H.  Porter).^ 

Not  infrequently  patients  exhibit  marked  idiosyncrasies  to  the 
nitrites:  some  bear  them  very  badly  and  are  much  more  affected 
by  one  member  of  the  nitrite  group  than  by  another;  others  can 
take  enormous  doses  (one  grain  of  nitroglycerin  daily  has  been 
given  with  apparent  benefit).  The  administration  of  the  nitrites 
coincidently  with  digitalis  is  a  therapeutic  blunder.  The  effect  of 
the  former  will  have  passed  off  long  before  that  of  the  latter  has 
begun  to  act.  Nitroglycerin  has  a  retarding  effect  on  renal  secretion 
(Loeb).  Nitrite  of  amyl  acts  primarily  upon  the  cerebral  vessels — 
more  so  than  the  other  nitrites. 

Average  Blood- pressure  Results  from  Administration  of  Nitroglycerin, 

Sodium  Nitrite,  and  Erythrol  Tetranitrate  to  Patients  with 

Arteriosclerosis.     (Wallace  and  Riiiger.)^ 

Time  of  Time  of  Time  of  Minimum 

beginning  maximum  duration  extent  of 

action.  effect.  of  action.          action. 

Drug.                                Min.  Min.  Min.  Mm.  Hg.        Per  cent. 

Nitroglycerin,  y\j  gr.     .      .       2  8  35  32  17 

Sodium  nitrite,  2  gr.      .      .      15  45  120  53  25 

Erythrol  tetranitrate,  2  gr.  .  30  60  180  60  30 

In  hypertensive  cases  the  response  is  sometimes  less  prompt 
(delayed  absorption)  and  the  action  more  prolonged  (delayed  excre- 
tion). The  percentage  fall  is  much  the  same  in  both  tables.  Head- 
ache is  less  frequent  in  high-pressure  cases;  indeed,  it  is  often 
relieved  by  these  drugs. 

>  Jour.  Am.  Med.  Assn.,  August  3,  1912. 

'  The  Lowering  of  Blood-pressure  by  the  Nitrite  Group,  Jour.  Am.  Med.  Assn., 
1909,  liii,  1630. 


350  EFFECTS  OF  DRUGS  ON  BLOOD-PRESSURE 

The  employment  of  the  nitrites  in  hypertension  is  purely  symp- 
tomatic viedication.  It  temporarily  relieves  high  pressure  as  certain 
forms  of  headache  are  relieved  by  acetanilid.  It  does  not  affect 
the  underlying  cause,,  and  if  used  indiscriminately  may  do  actual 
harm.  The  nitrites  are  often  given  in  too  small  doses  and  too 
infrequently,  especially  since  toleration  is  rapidly  established; 
jljj  grain  of  nitroglycerin  is  often  a  better  dose  than  y^^,  and  as 
high  as  tV  may  be  given  in  emergencies. 

The  nitrites  are  essentially  emergency  drugs  to  be  given  in  case 
of  a  threatened  apoplexy  or  cardiac  failure  from  hypertension, 
etc.  The  splanchnic  dilatation  relieves  the  systemic,  especially  the 
intracranial  pressure,  but,  of  course,  after  intracerebral  vascular 
rupture  has  occurred  the  nitrites  are  contra-indicated.  Many 
preparations  on  the  market  are  inert.  The  dosage  must  be  based 
on  the  physiological  effect,  flushing,  headache,  and  a  fall  of  pressure. 
Nitroglycerin  is  also  used  as  a  therapeutic  test  agent  to  determine 
whether  certain  symptoms  are  due  to  spastic  vascular  contraction. 
It  is  contra-indicated  in  arterial  hypotension,  and  should  therefore 
not  be  used  as  a  primary  cardiac  stimulant  in  acute  febrile  disease 
or  shock. 

Form  of  Administration. —  Nitrite  of  amyl,  in  glass  capsules  (to 
be  kept  in  the  dark),  to  be  crushed  in  a  handkerchief  and  inhaled. 
The  primary  fall  of  pressure  is  followed  by  a  rise  to  above  the  original 
level  (Hewlett) .  In  cases  of  cardiac  weakness,  instead  of  a  secondary 
rise  of  6  to  10  mm.,  a  fall  of  pressure  occurs  (Abrams). 

Nitroglycerin,  perferably  as  a  1  per  cent,  solution  (spiritus 
glycerylis  nitratis),  to  be  swallowed,  or  as  tablets  to  be  dissolved 
on  the  tongue.    Dose  yiir  to  yV  grain. 

Sodium  Nitrite. — Tablets  or  be  swallowed  or  dissolved  on  the 
tongue.     Dose:  gr.  ss  to  gr.  ij  (solutions  deteriorate  rapidly). 

Erythrol  Tetranitrate. — Tablets.  Dose:  gr.  j  to  gr.  ss.  Erythrol 
tetranitrate  produces  the  most  severe  headaches. 

Mannitol  nitrate  (gr.  j) ;  effect  even  more  prolonged  than  erythrol. 

On  the  whole  the  spiritus  glycerylis  nitratis  is  the  best  prepa- 
ration, both  because  of  its  reliability  and  because  of  the  ease  with 
which  the  dose  can  be  increased. 

If  a  prolonged  and  gradual  effect  is  desired  the  nitrites  should 
be  given  after  meals.  If  taken  between  meals  the  drug  should  be 
well  diluted.  Sudden  effects  are  generally  as  useless  as  they^are 
undesirable. 

Summary. — 1.  "The  general  indications  for  the  use  of  nitro- 
glycerin are  (a)  to  relieve  symptoms  of  localized  arteriosclerosis 


OPIUM  351 

or  arterial  spasm  in  vitally  important  regions  of  the  body  and 
when  there  is  pain  due  to  contracted  or  diseased  arteries  in  other 
regions;  (b)  to  reduce  general  high  blood-pressure  in  selected 
cases,  if  its  continuance  threatens  accidents  to  the  cardiovascular 
apparatus;  and  (c)  to  clear  the  diagnosis  (see  p.  311). 

2.  "The  chief  contra-indications  to  the  use  of  nitroglycerin  are 
(a)  low  or  relatively  low  blood-pressure;  {h)  advanced  chronic 
nephritis  with  very  high  blood-pressure  and  toxemic  conditions 
producing  high  blood-pressure,  as  a  rule;  and  (c)  the  presence  of 
an  idiosyncrasy  in  regard  to  its  action."^ 

Opium. — In  some  cases  of  hypertension  (angina  pectoris,  broken 
compensation,  etc.)  morphin  is  an  indispensable  drug.  It  often 
produces  a  most  satisfactory  fall  of  pressure  as  well  as  relief  from 
symptoms,  the  former  being  doubtless  largely  due  to  its  general 
sedative  influence  on  the  nervous  system  and  its  stimulation  of  the 
vagus  nerve.  Under  its  influence  the  cyanotic  skin  is  often  replaced 
by  a  pink  flush  indicating  a  dilatation  of  the  peripheral  circulation. 
The  danger  of  this  drug  in  nephritis  has  been  greatly  overestimated. 
The  beneficial  effects  of  opium  are  also  in  part  due  to  its  effect  on 
the  respiration.  Edsall  has  shown  that  superficial  rapid  respira- 
tions such  as  are  seen  in  cardiac  dyspnea,  etc.,  are  functionally 
less  efficient  than  slower  labored  movements.^  It  tends  to  lower 
blood-pressure  by  central  vagal  slowing  of  the  pulse.^  In  the  case 
of  normal  hearts  during  nocturnal  sleep  the  pulse  rate  is  slowed 
about  twenty  beats  per  minute,  and  although  the  slowing  thus 
produced  become  progressively  less,  the  worse  the  cardiac  com- 
pensation, yet  notwithstanding  the  establishment  of  sleep,  induces 
very  considerable  cardiac  rest.^  Morphin  produces  a  mild,  codein 
only  a  slight,  dilatation  of  the  coronary  arteries.  Narcotin  and 
papaverin  cause  marked  dilatation.  But  morphin  and  narcotin 
combined  have  less  effect  than  either  separately.  A  combination 
of  caffein  (which  of  itself  produces  coronary  dilatation)  with  papa- 
verin causes  dilatation  of  the  coronary  ring.* 

Papaverin  in  addition  to  its  analgesic  effect  produces  a  slight 
slowing  of  cardiac  rate,  and  increased  myocardial  tonicity  and  a 

*  Cornwell,  E.  E.:  When  and  How  to  Use  Nitroglycerin,  Jour.  Am.  Med.  Assn., 
1913,  Ixi,  118. 

'  Edsall,  D.  L. :  The  Efficiency  and  Significance  of  Different  Forms  of  Respiration, 
Tr.  Assn.  Am.  Phys.,  1912,  xxvii,  560. 

'  Van  Egmond:  Die  Wirkimg  des  Morphins  auf  d.  Herz,  Arch.  f.  exp.  Path., 
1911,  Ixv,  197. 

*  Klewitz,  F.:     Der  Puis  im  Schlaf,  Deutsch.  Arch.  f.  klin.  Med.,  1913,  cxii,  38. 

'  Macht,  D.  I.:  Action  of  the  Opium  Alkaloids,  Jour.  Am.  Med.  Assn.,  1915, 
bdv,  1489. 


352  EFFECTS  OF  DRUGS  ON  BLOOD-PRESSURE 

fall  of  blood-pressure  resulting  from  peripheral  action  on  the  vascular 
walls. ^  These  properties  suggest  its  use  in  angina  pectoris  and 
arterial  hypertension  when  an  analgesic  or  sedative  is  required. 
In  the  last-named  qualities  its  seems  to  be  the  equal  of  codein. 

Pilocarpin. — Is  a  powerful  dikphoretic,  the  physiological  action  of 
which  is  directly  opposite  to  that  of  atropin.  Full  doses  slow  the 
cardiac  rate  and  diminish  contraction  through  vagus  stimulation. 
Still  larger  doses  depress  the  heart  muscle  directly.  Toxic  doses 
cause  peripheral  vasodilatation  by  depressing  the  vasoconstrictor 
centre.    It  therefore  tends  to  lower  blood-pressure. 

It  has  long  been  used  as  a  diaphoretic  in  renal  disease,  especially 
in  conjunction  with  hot  packs  or  hot-air  baths  if  the  patient  does 
not  sweat  sufficiently  from  the  latter  procedures  alone.  It  must, 
however,  be  given  with  caution  in  cases  of  heart  weakness,  since 
it  may  produce  pulmonary  edema.  This  accident  can,  however, 
be  promptly  corrected,  if  treated  in  time  by  full  doses  of  atropin 
(gr.  3"V  hypodermically) .  The  usual  dose  of  pilocarpin  for  adults 
subcutaneously  is  to"  grain  (0.006). 

It  has  been  recommended  in  small  doses  (gr.  ^V)  thrice  daily  in 
water  after  meals  to  relieve  arterial  hypertension  and  its  associated 
symptoms,  especially  headache.^ 

Pineal  Extract. — Aqueous  extracts  of  pineal  gland  were  found  by 
Eyster  and  Jordan^  and  by  Ott  and  Scott*  to  produce  a  slight  fall 
of  pressure  when  injected  intravenously.  Other  investigators, 
however,  have  shown  that  the  blood-pressure  effects  of  pineal 
extract  are  insignificant.^ 

Pituitary  Extract. — ^The  infundibular  portion  of  the  gland  has  a 
more  prolonged  though  less  marked  and  rapid  blood-pressure 
raising  effect  than  epinephrin.  Too  frequently  repeated  it  depresses 
respiration.  It  also  has  a  diuretic  effect  due  to  direct  stimulation 
of  the  renal  cells,  usually  aided  probably  by  a  concomitant  vaso- 
dilatation, because  there  is  no  constant  relation  between  pituitrin 
diuresis  and  either  systolic  or  pulse-pressure  or  the  ratio  between 
them.  As  a  general  rule,  however,  it  is  accompanied  by  a  decreased 
pulse-pressure.®     Furthermore,  there  is  no  constant   relationship 

*  Macht,  D.  I.:  A  Pharmacological  and  Clinical  Study  of  Papaverin,  Arch.  Int. 
Med.,  1916,  xvii,  786. 

'Robinson,  W.  D.:  Pilocarpin  in  High  Blood-pressure,  Tr.  Am.  Climat.  Assn., 
1914,  XXX,  290. 

3  Eyster,  J.  A.  E.,  and  Jordan,  H.  E.:    Am.  Jour.  Physiol.,  1910-11,  xxiii,  25. 

<Ott,  J.,  and  Scott,  J.  C:  Cycl.  and  Med.  Bull.,  1912,'v.  207. 

6  Dixon  and  Halliburton:  The  Pineal  Body,  Quart.  Jour.  Exper.  Physiol.,  1909, 
ii,  282. 

*  Hoskins  and  Means:  Relation  of  Vascular  Conditions  to  Pituitiin  Diuresis, 
Jour.  Phar.  and  Exper.  Therap.,  1913,  iv,  No.  5. 


STROPHANTHUS  353 

between  renal  volume  and  pituitary  diuresis/  with  local  renal  vaso- 
dilatation.2  It  stimulates  the  heart  but  in  animals  has  no  efl'ect 
upon  the  vasomotor  centre.  It  stimulates  intestinal  peristalsis 
and  is  sometimes  useful  for  tympanites.  It  may  be  given  hypo- 
dermically,  intravenously,  or  by  mouth.  It  may  be  used  instead 
of  epinephrin  in  cases  of  temporary  hypotension  or  in  cases  of  pul- 
monary hemorrhage,  q.  v.  It  causes  contraction  of  the  peripheral 
arterioles,  increases  cardiac  contraction,  and  slows  the  pulse.  These 
results  are  due  to  a  direct  effect  upon  the  cardiac  and  arterial  mus- 
culature. It  has  been  recommended  in  all  cases  in  which  lowered 
blood-pressure  is  due  to  loss  of  splanchnic  vascular  tone,  and  in 
hypotension  due  to  shock  or  toxemia,  especially  in  combination  with 
saline  infusion.^  Musser,  Jr.,"*  who  administered  pituitary  extract 
by  mouth  (0.065  dried  gland,  q.  d.)  obtained  very  constantly  a 
distinct  elevation  of  blood-pressure  (up  to  28  mm.  Hg.)  w^hich  often 
persisted  for  a  time  after  discontinuance  of  the  drug.  The  injection 
of  1  c.c.  of  pituitrin  is  followed  within  a  few  minutes  by  a  rise  of 
pressure  averaging  25  to  30  mm.,  which  lasts  for  about  half  an  hour.^ 
Diarrhea  was  sometimes  produced.  Commerical  preparations  of 
the  posterior  lobe  vary  greatly  in  potency,  and  should  be  standard- 
ized. Roth  suggests,  by  their  action  on  the  isolated  uterus  of  the 
virgin  guinea-pig. 

Spartein. — Experimentally  given  to  dogs  in  doses  of  5  mg.  per  kilo, 
spartein  produces  a  slight  initial  rise  of  blood-pressure  and  an 
increased  pulse  rate.  This  increase  of  pressure  is  brief  and  is 
followed  by  a  pronounced  fall.  In  from  one  to  three  minutes 
pressure  returns  to  normal.  If  the  dosage  is  doubled  a  more  marked 
and  prolonged  fall  of  pressure  occurs.  The  latter  dose  if  repeated 
often  kills.®  Spartein  sulphate  stimulates  the  vagal  ganglia  and 
depresses  the  heart  muscle.  It  slightly  stimulates  the  ganglia 
of  the  vasoconstrictor  nerves  but  clinically  produces  no  demon- 
strable rise  of  blood-pressure. 

Strophanthus. — The  action  of  this  drug  is  essentially  that  of 
digitalis.  Its  effects  are  somewhat  less  lasting,  perhaps  because, 
as  suggested  by  Eggleston,  it  is  less  firmly  fixed  in  the  tissues  and 
more  promptly  eliminated.     If  used,  it  should  be  given  intraven- 

>  Schaeffer  and  Herring:    Philos.  Tr.  Royal  Soc,  Sect.  B,  1908,  cxcix,  1. 

*  King  and  Stoland:    Am  Jour.  Physiol.,  1913,  xxxii,  405. 
'Klotz:    Internat.  Congr.  Physiotherapy,  Berlin,  1913. 

*  Effects  of  Continuous  Administration  of  the  Pituitary  Gland,  Am.  Jour.  Med.  Sc, 
1913,  cxlvi,  208. 

5  Arbuck,  S.  S.,  and  Rongy,  J.  A.:    New  York  Med.  Jour.,  1914,  p.  878. 
'  Haskell,  C.  C,  and  Thomas,  H.  B. :    Physiological  Action  of  Spartein  Sulphate, 
Old  Dominion  Jour.  Med.  and  Surg.,  1916,  xxii.  No.  2. 
23 


354  EFFECTS  OF  DRUGS  ON  BLOOD-PRESSURE 

ously  in  the  form  of  strophanthin.^  Its  absorption  from  the  gastro- 
intestinal tract  is  variable  and  uncertain  (Hatcher). 

Strophanthin  and  ouabain  have  been  shown  to  act  upon  the  heart 
even  in  febrile  conditions  in  their  characteristic  digitalis-like  manner, 
except  that  no  slowing  of  the  pulse  occurs  (Cohn).  If  the  heart 
does  not  respond  it  is  not  because  of  the  degree  of  fever,  but  perhaps 
owing  to  the  presence  of  toxins;^  indeed,  it  appears  that  ouabain 
is  more  prompt  in  its  effect  upon  the  rabbit's  heart  if  the  bodily 
temperature  is  raised. 

Salvarsan. — Experimentally,  small  doses  produce  but  slight  and 
temporary  effects  on  blood-pressure.  Moderate  doses  cause  a  slight 
fall  at  the  end  of  two  minutes,  a  secondary  rise  and  a  tertiary 
decline  (two  to  six  minutes).  Large  doses  lower  pressure  at  once. 
Both  alkaline  and  acid  solutions  of  salvarsan  experimentally  cause 
a  fall  of  blood-pressure.  If  an  excess  of  alkali  is  added  blood- 
pressure  may  rise  but  this  is  purely  due  to  the  alkali  which  has 
physiologically  overantagonized  tKe  salvarsan.  Cardiac  dilatation 
may  also  be  directly  produced  by  salvarsan  and  in  such  an  event 
the  heart  shows  changes  in  rate  and  volume  before  the  blood- 
pressure  falls.  Sudden  death  following  its  administration  is  there- 
fore generally  a  cardiac  death  (Luithlen).^  The  fatal  termination 
has  also  been  ascribed  (Hoke  and  Rihl)  to  a  central  vasomotor 
depression.  The  administration  of  sodium  arsenate  produces  a 
marked  fall  in  blood-pressure  without  any  direct  effect  upon  the 
heart,  showing  that  the  action  of  salvarsan  is  not  identical  with 
that  of  arsenic.  In  vascular  disease,  doses  which  are  not  toxic  to 
the  heart  may  cause  a  sudden  fatal  termination  through  their 
effect  on  the  bloodvessels.  Salvarsan  causes  contraction  of  the 
coronary  arteries  and  a  decreased  pulse  rate.'*  Rindflleisch  has 
emphasized  the  danger  of  salvarsan  injection  in  status  thymo- 
lymphaticus,  and  has  reported  two  cases  in  which  a  summation  of 
depression,  salvarsan  and  thjTnus  extract  caused  death.^ 

The  depression  of  blood-pressure  caused  by  salvarsan  in  medicinal 
dosage  is  never  sufficiently  great  to  endanger  a  normal  circulatory 

>  Intramuscular  dose:  cryst.  strophanthin  (ouabain)  gr.  yj^' (0.0005  gram),  once 
in  twenty-four  hoiu-s.  Intravenously  in  1  to  6000  saline  solution  of  strophanthin 
(Boehringer),  gr.  tio  to  A  (0.0005  to  0.001  gram). 

*  SoUmann,  Mendenhall  and  Stengel:  The  Influence  of  Temperatuie  and  Concen- 
tration on  the  Qualitative  Reaction  of  the  Heart  to  Ouabain,  Jour.  Phar.  and  Exp. 
Therap.,  1915,  vi,  533. 

'  Die  Exper.  Analyse  der  Salvarsanwirkung,  Ztschr.  f.  exp.  Path.  u.  Therap.,  1913, 
xiii,  495. 

*  Cznbalski,  F.:   Abstr.  Centralbl.  f.  d.  ges.  inn.  Med.,  1913,  iv,  149. 

'  Rindfleisch,  W.:  Status  Thymolymphaticus  u.  Salvarsan,  Berl.  klin.  Wchnschr., 
1913,  i,  542. 


THYROID  EXTRACT  355 

system,  but  this  form  of  medication  may  be  definitely  dangerous 
in  cases  of  marked  hypotension.^ 

Neosalvarsan. — During  the  administration  of  neosalvarsan  both 
systolic  and  diastolic  pressures,  although  variable,  are  usually 
increased  apparently  as  a  result  of  excitement.  After  the  injection 
(seven  hours)  both  pressures  are  decreased  and  remain  so  for 
several  days.  At  first  the  systolic,  later  the  diastolic,  pressure 
is  most  affected. 2 

Strychnin. — Strychnin  is  still  used  in  the  treatment  of  symptoms 
associated  with  low  blood-pressure,  especially  if  the  vasomotor 
depression  is  central  in  origin.  It  acts  reflexly  and  its  beneficial 
effects  are  indirect.  It  is  capable  of  increasing  the  stimulability 
of  the  vasomotor  system.'  Like  caffein,  its  effects  are  more  pro- 
nounced if  the  blood-pressure  is  subnormal.  Marvin^  found  a 
marked  increase  in  pressure  after  doses  of  gr.  -^^  to  2ir  in  healthy 
students,  but  practically  no  results  from  smaller  doses.  The  pulse 
rate  was  invariably  slowed.  The  recent  investigations  of  New- 
burgh^  have  shown,  however,  that  in  infectious  diseases  in  medicinal 
doses,  strychnin  does  not  increase  the  cardiac  output,  slow  the 
pulse,  or  materially  increase  blood-pressure.  Nor  is  strychnin 
of  value  as  a  heart  stimulant  in  acute  or  chronic  cardiac  failure.^ 
Although  the  administration  of  strychnin  may  do  good,  especially 
in  essential  hypotension,  its  effects  are  due  to  its  stimulation  of  the 
brain  and  spinal  cord  and  not  to  any  direct  action  upon  the  circula- 
tory mechanism. 

Thyroid  Extract. — Injected  intravenously,  thyroid  extract  pro- 
duces, as  do  the  extracts  of  most  tissues  and  organs,  a  fall  of  blood- 
pressure.  It  has  been  suggested  that  the  hypotensive  effect  of 
thyroid  substance  is  due  to  cholin,  but  Vincent  believes  that  the 
depressor  effect  is  due  to  other  substances. 

Since  a  diminished  thyroid  secretion  or  an  increased  adrenal 
secretion  tends  to  raise  blood-pressure,  and  since  these  secretions 
appear  to  neutralize  each  other,  and  as  exophthalmic  goitre  patients 
often  have  relaxed  peripheral  bloodvessels,  the  administration  of 

*  Sieskind:  Das  Verbal  ten  des  Blutdruckes  bei  intravenosen  Salvarsaninjek- 
tionen,  Mlinchen.  med.  Wchnschr.,  1911,  No.  11. 

*Rolleston:     Influence  of  Neosalvarsan  on  Blood-pressure,  British  Med.  Jour., 
1915,  ii,  285. 
'  Sollmann  and  Pilcher:   Am.  Jour.  Physiol.,  1912,  xxx,  369. 

*  Arch.  Int.  Med.,  1913,  xi,  418. 

'  Newburgh,  L.  H.:  Strychnin  and  Caffein  as  Cardiovascular  Stimulants  in  Acute 
Infectious  Disease,  Arch.  Int.  Med.,  1915,  xv,  458. 

«  Newburgh,  L.  H.:  On  the  Use  of  Strychnin  in  Broken  Cardiac  Compensation, 
Am.  Jour.  Med.  Sc,  1915,  cxlix,  696. 


356  EFFECTS  OF  DRUGS  ON  BLOOD-PRESSURE 

thyroid  gland  seems  justified  as  a  therapeutic  measure  in  hyper- 
tension. It  stimulates  thyroid  secretion  and  cutaneous  activity. 
It  is  best  given  in  small  doses,  one  to  three  grains  daily.  Such 
treatment  is  sometimes  attended  by  beneficial  results  which  not 
infrequently  outlast  its  administration.  The  experiments  of  Reid 
Hunt  indicate  that  some  of  the  effects  of  diet  are  due  to  its  action 
on  the  thyroid  gland  (see  Exophthalmic  Goitre,  page  367).^ 

Vasotonin  (  Yohimbin  and  Urethane). — ^The  results  reported  upon 
the  use  of  this  drug  are  contradictory.  Favorable  action  has  been 
claimed  both  experimentally  and  clinically  by  some  observers.  A 
lowering  of  pressure  without  depression  of  the  heart  or  vasomotor 
or  respiratory  centres  has  been  reported.  It  is  given  in  1  c.c.  doses 
daily  or  on  alternate  days,  and  may  be  administered  hypodermically. 
It  is  said  to  cause  Icos  headache  than  the  nitrites,^  and  to  produce 
dilatation  of  the  vessels  in  the  extremities  especially.  It  has  been 
recommended  for  angina  pectoris  and  arterial  hypertension  by 
Fellner^  who  reports  favorable  subjective  and  objective  results. 
He  states  that  it  does  not  produce  the  aphrodisiac  effects  of  yohim- 
bin, nor  does  it  produce  cardiac  depression. 

Veratrum  Viride. — Is  employed  by  some  physicians  to  lower 
blood-pressure  in  eclampsia.  Just  why,  is  difficult  to  understand, 
since  the  drug  is  not  a  vasodilator.  In  small  doses  it  "exercises 
its  effect  upon  blood-pressure  neither  peripherally  through  its 
action  on  the  vessel  walls,  or  on  the  vasomotor  nerve  endings,  nor 
through  a  direct  action  on  the  vasomotor  centre  or  on  the  heart, 
but  reflexly  through  the  afferent  vagus  fibers."*  Clinically  this 
drug  has  never  been  widely  used  because  of  its  danger,  uncertainty 
of  action,  and  because  its  pharmacological  status  is  still  unsatis- 
factory. It  is  usually  employed  in  the  form  of  the  tincture  in  doses 
of  10  to  20  minims.  The  effective  therapeutic  dose  of  the  tincture 
of  veratrum  album,  according  to  Collins,^  ranges  between  30  and 
75  m.  Such  doses  reduce  the  pulse  rate  from  12  to  42  beats  per 
minute,  and  lower  blood-pressure  in  both  its  phases  about  30  mm, 
Hg.  In  hypertensive  cases  the  systolic  pressure  may  be  even  more 
reduced,  but  the  diastolic  pressure  is  much  less  affected. 

iHunt:  Jour.  Am.  Med.  Assn.,  October  19,  1907,  p.  1323;  September  23,  1911, 
p.  1032. 

'  Miiller  and  Fellner:  Ueber  Vasotonin,  ein  nenes  druckherabsetzendes  Gefaess- 
mittel,  Therap.  Monatshefte,  1910,  xxiv,  285. 

'  Klinische  Erfahrungen  iiber  Vasotonin,  Kong.  f.  inn.  Med.,  1910,  xxvii,  647. 

*  Cramer,  W. :  The  Action  of  Veratrum  Viride,  Jour.  Pharm.  and  Exper.  Therap., 
1915,  vii,  64. 

'Collins,  R.  J.-  The  Clinical  Actions  of  Veratrum,  Arch.  Int.  Med.,  1915,  xvi,  54. 


EFFECT  OF  DRUGS  ON  THE  CORONARY  ARTERIES     357 

Tohimbin. — Pongs^  reports  in  twenty- two  cases  after  doses  of 
0.5  to  2  cm.  a  slight  fall  of  pressure  followed  by  a  secondary  rise 
up  to  35  per  cent.,  reaching  its  high  point  in  forty-five  minutes 
and  lasting  one  to  five  hours.  No  hypotensive  effects  were  demon- 
strable even  with  larger  dosage;  no  untoward  results — uremia,  angina 
pectoris — were  noted.     Genital  manifestation  occurred  only  twice. 

THE  EFFECT  OF  DRUGS  ON  THE  CORONARY  ARTERIES. 

It  seems  evident,  a  priori,  that  the  local  effect  of  different  forms 
of  medication  upon  the  pressure  and  blood  flow  in  the  coronary 
arteries  must  be  of  extreme  importance  in  the  selection  of  our 
therapeutic  remedies.  The  circulation  in  the  coronary  arteries 
is  directly  dependent  upon  blood-pressure. 

This  question  has  been  studied  experimentally  by  noting  (1 )  the 
contraction  or  relaxation  of  arterial  strips,  and  (2)  the  amount  of 
blood  flow  from  an  opened  artery.  Such  investigations  have, 
however,  not  led  to  uniform  results,  because,  as  Rabe'^  pointed  out, 
in  either  method  the  experimental  heart  is  deprived  of  the  effect 
of  the  central  nervous  system  and  is  functionating  under  abnormal 
conditions. 

Voegtlin  and  Macht^  found  that  digitoxin,  digitalin,  strophan- 
thin,  and  buff  agin  produced  contraction,  and  that  the  nitrites  and 
digitonin,  digalen,  dilatation  of  the  coronary  artery.  If  these 
findings  hold  good  under  normal  conditions  they  would  in  a  measure 
justify  the  coincident  use  of  the  nitrites  with  digitalis  or  strophan- 
thus.  Rabe  noted  contraction  from  strophanthin,  digitalin,  epi- 
nephrin,  and  slight  contraction  from  sodium  nitrite  and  caffein. 
Myer's  experiments  (dogs  and  cats)  corroborate  the  belief  that 
epinephrin  dilates  the  coronary  arteries  and  increases  blood  flow 
through  them.^  Although  this  effect  has  been  noted  in  numerous 
animals  it  appears  that  in  the  monkey  and  probably  in  man  epi- 
nephrin causes  coronary  constriction.  This  is  perhaps  due  to  the  fact 
that  in  the  latter  species  the  coronary  arteries  are  supplied  with 
constrictor  nerves  of  true  sympathetic  (thoracicolumbar)  origin.^ 
An  increase  of  the  CO2  content  of  the  blood  causes  dilatation  of 

1  Ztschr.  f.  exp.  Path.  u.  Therap.,  1912,  x,  479. 

*  Die  Reaction  der  Kranzgefasse  auf  Arzneimittel,  Ztschr.  f.  exp.  Path.  u.  Therap., 
1912,  xi  (bibliography). 

'  Jour.  Pharm.  and  Exp.  Therap.,  September,  1913. 

*  Myer:  Zur  Frage  d.  Adrenalin  Wirkung  auf  d.  Coronarkreislauf,  Berl.  klin. 
Wchnschr.,  1913,  1,  No.  20. 

'  Barbour,  H.  G.,  and  Prince,  A.  L.:  Influence  of  Epinephrin  upon  the  Coronary 
Circulation  of  the  Monkey,  Jour.  Exp.  Med.,  1915,  xxi,  330. 


358  EFFECTS  OF  DRUGS  ON  BLOOD-PRESSURE 

the  coronary  arteries,  together  with  cardiac  dilatation  and  a  fall 
of  blood-pressure.  Experimental  asphyxia  causes  an  even  greater 
coronary  dilatation,  which  increases  in  proportion  to  increased 
demands  upon  the  heart  muscle.^ 

INTRAVENOUS  THERAPY. 

The  increased  employment  of  intravenous  therapy  warrants  a 
brief  mention  of  this  topic  here.  While  sometimes  necessary  and 
perhaps  often  advisable,  the  physician  should  not  lose  sight  of  the 
fact  that  aside  from  the  possibility  of  introducing  infectious  material 
or  of  producing  thrombosis,  intravenous  injections  are  often  fol- 
lowed by  a  prompt  and  sometimes  serious  fall  of  blood-jjressure. 
This  phenomenon  which  has  been  explained  in  the  case  of  drugs 
as  resulting  from  endocardial  irritation,  may  occur  after  the  intra- 
venous injection  of  substances  which  administered  orally  or  intra- 
muscularly, have  no  such  demonstrable  effect.  Quinine  and 
potassium  salts  directly  depress  the  heart  muscle  and  sudden  death 
has  occurred  following  the  use  of  iron  preparations  containing 
peptone.^ 

THE  EFFECT  OF  MEDICATION  ON  VENOUS  BLOOD- 
PRESSURE. 

The  experiments  of  Capps  and  Mathews^  carried  out  upon  dogs 
under  light  ether  anesthesia  yielded  the  following  results : 

The  Digitalis  Grouj). — The  venous  pressure  was  not  materially 
altered. 

Epinephrin.  —  Small  doses  produced  no  effect.  Large  doses 
caused  a  rise  of  from  10  to  80  mm.  The  rise  in  venous  pressure 
was  coincident  and  coextensive  with  halting  irregular  heart  action, 
and  presumably  the  result  of  it  rather  than  dependent  upon  yeno- 
motor  stimulation. 

Pituitrin. — Acted  similarly  to,  but  more  feebly  than  epinephrin. 
•  Caffein. — This  drug  had  no  appreciable  effect. 

Strychnin. — Had  no  effect  on  venous  pressure  except  in  toxic 
doses,  in  which  it  caused  a  rapid  increase  of  pressure. 

The  Nitrites. — Both  inhalation  and  injection  of  these  substances 
causes  a  decided  fall  in  venous  pressure,  due  apparently  to  depres- 
sion of  the  peripheral  venous  nerve  endings. 

1  Markwalder  and  Starling:  A  Note  on  Some  Factors  which  Determine  the  Blood- 
flow  through  the  Coronary  Circulation,  Jour.  Physiol.,  1913,  xlvii,  275. 

»  Edit.,  Jour.  Am.  Med.  Assn.,  November  11,  1916,  p.  1450. 

'  Venous  Blood-pressure  as  Influenced  by  the  Drugs  Employed  in  Cardiovascular 
Therapy,  Jour.  Am.  Med.  Assn.,  1913,  Ixi,  388. 


EFFECT  OF  DRUGS  ON  THE  PULMONARY  ARTERY      359 

Morphin. — This  drug  in  small  doses  had  little  effect;  in  large 
doses  it  lowered  venous  pressure,  but  not  nearly  to  the  extent  that 
did  the  nitrites. 

Alcohol. — Large  doses  increased  venous  pressure  in  proportion 
to  the  degree  of  cardiac  and  arterial  depression  produced. 

THE  EFFECT  OF  DRUGS  ON  THE  VASOMOTOR  CENTRE.^ 

Aconite  in  non-toxic  doses  has  no  effect.  Ergot  and  ergotoxin 
have  practically  no  action.  Ether  may  produce  moderate  stimu- 
lation but  often  is  without  effect.  Strophanthus  stimulates  the 
centre  moderately,  whereas  digitalis  has  much  less,  if  any,  action. 
Neither  of  the  last  two  drugs  produce  sufficient  effect  to  influence 
the  total  action  of  the  drug.  Nicotin  stimulates  the  centre. 
Spartein  has  no  direct  effect.  Pituitary  (infundibular)  extract 
stimulates  more  frequently  than  it  depresses,  but  a  direct  effect 
is  generally  not  demonstrable.  When  effects  do  occur  they  are 
generally  due  to  the  rise  in  blood-pressure  (stimulation  of  the  vaso- 
motor centre)  or  to  respiratory  embarrassment  (depression  of  the 
centre).  Hydrastin  and  berberin  are  apparently  without  action 
on  the  centre.  Histamin  has  no  direct  action,  but  a  fall  of  pressure 
generally  produces  moderate  stimulation.  Chloroform  produces  a 
direct  depression.  The  nitrites  usually  cause  moderate  stimulation, 
never  a  direct  depression.  The  stimulation  is  probably  due  to  the 
anemia  caused  by  peripheral  lowering  of  blood-pressure.  Strychnin 
except  in  dangerously  toxic  doses  exerts  no  effect,  and  even  in  such 
dosage  stimulation  may  not  be  demonstrable..  Camphor  is  likewise 
without  effect. 

THE  EFFECT   OF  DRUGS  ON  THE    (ISOLATED)  PULMONARY 

ARTERY.2 

Epinephrin  causes  powerful  constriction.  After  ergotoxin  and  a 
number  of  other  drugs  the  action  of  epinephrin  is  inhibited.  These 
observations  point  strongly  toward  a  vasomotor  supply  of  the 
pulmonary  artery. 

Digitalis. — ^With  the  exception  of  digitonin  all  of  the  digitalis 
bodies  produce  a  constriction.  Digitonin  causes  a  dilatation.  The 
nitrites  cause  a  constriction  of  the  pulmonary  ring. 

>  Pilcher,  J.  D.,  and  SoUmann,  T. :  Studies  on  the  Vasomotor  Centre,  Jour.  Phar. 
and  Exp.  Therap.,  1914-15,  vi. 

-  Macht,  D.  I.:  Action  of  Drugs  on  the  Isolated  Pulmonary  Artery,  Jour.  Phar. 
and  Exp.  Therap.,  1914-15,  vi,  13. 


CHAPTER  XV. 

METABOLIC  DISEASES  AND  MISCELLANEOUS 
CONDITIONS. 

Diabetes. — ^Experimental  Evidence. — Recent  researches  indicate 
that  glycosuria  is  in  some  way  related  to  the  secretion  of  the  adrenal 
glands.  Sugar  excretion  can  be  induced  by  the  injection  of  epi- 
nephrin.  The  latter  also  produces  a  marked  rise  of  blood-pressure 
through  vasoconstriction.  Neubauer's^  investigations  have  shown 
that  other  substances  which  raise  blood-pressure  (e.  g.,  barium 
chloride)  may  also  induce  glycosuria,  whereas  narcotic  drugs, 
opium,  chloral,  alcohol,  etc.,  which  tend  to  lower  blood-pressure, 
may  diminish  or  prevent  the  occurrence  of  glycosuria  after  puncture 
of  the  roof  of  the  fourth  ventricle.  It  has  further  been  shown  that 
when  sugar  excretion  is  brought  about  by  vasoconstrictor  drugs 
it  is  associated  with  marked  hepatic  hyperemia.  A  local  stasis 
of  blood  in  the  liver  will,  it  seems,  bring  about  this  liberation  of 
glycogen  in  the  form  of  glucose,  with  an  attendant  hyperglycemia 
and  a  glycosuria.  It  appears  that  transient  glycosuria  may  be 
brought  about  by  the  same  emotional  states— pain,  rage,  fear, 
excitement — ^as  those  which  cause  an  increased  outpouring  of  epi- 
nephrin  into  the  blood  stream.  Until  the  pathogenesis  of  diabetes 
has  been  more  thoroughly  established  no  definite  conclusions 
regarding  the  relationship  of  arterial  hypertension  to  this  disease 
can  be  drawn.  The  evidence  at  hand,  however,  suggests  that  a 
general  vasoconstriction,  when  accompanied  by  a  local  vasodila- 
tation of  the  hepatic  vessels,  may  account  for  some  cases  of  glyco- 
suria. Hagelberg  found  the  sugar  content  of  the  blood  abnormally 
high  in  twenty-six  cases  of  nephritis  or  arteriosclerosis,  and  suggested 
that  an  increased  adrenalin  content  of  the  blood  accounts  for  both 
the  hyperglycemia  and  the  hypertension. ^  It  is  more  likely,  how- 
ever, that  the  relationship  between  hypertension  and  glycosuria 
is  not  a  causal  one.    There  is  no  constant  relation  between  blood 

1  Ueber  d.  Wirkung  antiglycosurischer  Mittel  u.  iiber  Leberglucosurie,  Biocbem. 
Ztschr.,  1912,  xljii,  335. 

2  Hagelberg:  Berl.  klin.  Wchnschr.,  October  7,  1912. 


DIABETES 


361 


sugar  and  blood-pressure,  nor  is  there  a  sufficient  reason  for  assuming 
that  these  two  conditions  are  dependent  upon  a  common  etiological 
factor  (epinephrin) .     (See  Hyperglycemia,  page  295.) 

Clinical  Consideration. — Diabetes  bears  no  constant  relation  to 
blood-pressure.  Cases  occurring  in  advanced  life  often  show  hyper- 
tension as  the  result  of  renal  and  cardiovascular  arteriosclerosis, 
which  is  commonly  associated.  This  is  illustrated  by  the  following 
tables  published  by  Joslin:i 


The  Average  Blood-pbessures  of  Normal  and  Diabetic  Individuals. 


Normal  Individuals 

(Fisher) . 

Ages.                       Number. 

Average 
blood- 
pressure. 

Diabetic  Patients 

(Joslin). 

Ages.                      Number. 

Average 
blood- 
pressure 

15  to  20  .      .      .     281 

120 

15  to  20 

38 

121 

21  to  25  . 

.     785 

123 

21  to  25 

33 

122 

26  to  30  . 

.     791 

124 

26  to  30 

56 

121 

31  to  35  . 

.     689 

124 

31  to  35 

39 

120 

36  to  40  . 

.  2,111 

127 

36  to  40 

64 

125 

41  to  45  . 

.  6,740 

129 

41  to  45 

75 

139 

46  to  50  . 

.  4,471 

131 

46  to  50 

116 

143 

51  to  55  . 

.  2,371 

132 

51  to  55 

127 

154 

56  to  60  . 

.  1,100 

135 

56  to  60 

103 

154 

Over  60 

163 

156 

19,339 


127 


814 


139 


Joslin  encountered  a  fall  of  pressure  coincidently  with  a  disap- 
pearance of  glycosuria  only  once  in  814  cases.  He  suggests  that 
the  high  blood-pressure  in  diabetics  past  forty  years  of  age  is  due 
to  arteriosclerosis  possibly  induced  by  the  high  protein  feeding 
formerly  in  vogue. 

I  once  had  under  my  care  a  gentleman  of  sixty-eight  years, 
with  a  blood-pressure  of  185-85  mm.,  who  had  long  been  diabetic. 
Having  made  a  careful  study  of  his  own  case  he  had  succeeded  in 
keeping  himself,  sugar-free  by  careful  dieting  and  severe  muscular 
exercise.  He  had  made  the  observation  that  if  he  performed  enough 
physical  work  to  induce  copious  perspiration  he  could  metabolize 
a  certain  amount  of  glucose,  which  otherwise  was  excreted  by  the 
kidneys. 

iVll  went  well  for  several  years  until  he  developed  angina  pectoris 
which  prevented  his  exercise.  He  said  to  me  one  day,  "  If  I  exercise 
I  shall  die  of  angina  pectoris,  if  I  do  not  exercise  I  at  once  develop 
acidosis.  I  have  the  chance,  not  offered  to  many  men  of  choosing 
between  two  varieties  of  dying."  He  chose  angina  and  died  two 
months  later. 


»  The  Treatment  of  Diabetes  Mellitus,  Philadelphia,  2d  ed.,  1917,  p.  413. 


362     METABOLIC  DISEASES  AND  MISCELLANEO  US  CONDITIONS 


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GOVT  363 

Diabetes  in  the  young  is  accompanied  by  normal  pressures. 
In  the  later  stages  hypotension  may  occur.  Blood-pressure  estima- 
tions may  be  of  diagnostic  value  in  differentiating  between  diabetic 
and  uremic  coma.  In  the  latter  condition  hypertension  is  the  rule 
until  the  terminal  fall  of  pressure  occurs,  whereas  diabetic  coma  is 
associated  with  hypotension.^  Although  this  occurs  less  constantly 
than  does  hypertension  in  uremia,  it  is  sometimes  an  early  mani- 
festation. The  so-called  "  diabetic  collapse"  which  has  been  believed 
to  occur  independently  of  coma,  appears  to  be  the  result  of  a  rapid 
fall  in  blood-pressure  due  to  cardiac  and  vasomotor  weakness, 
resulting  from  acidosis.  Experimentally  the  injection  of  jS-oxy- 
butyric  acid  causes  a  fall  of  blood-pressure. 

The  pulse  rate  is  increased  in  diabetes,  and,  as  has  been  empha- 
sized by  Benedict  and  Joslin,  stands  in  intimate  relation  with 
increased  metabolism.^  Preceding  the  onset  of  coma,  blood-pressure 
falls  sometimes  40  to  50  mm.  Hg.  Decrease  of  intra-ocular  tension, 
which  occurs  simultaneously,  is  well  known  and  results,  in  part 
at  least,  from  the  lowered  arterial  pension.  Blood-pressure  readings 
are  therefore  of  value  in  detecting  the  onset  of  coma  as  well  as  in 
indicating  treatment.  It  has  been  found  that  in  coma  cases  with  low 
blood-pressure  better  results  are  obtained  when  cardiovascular 
stimulants  are  combined  with  the  usual  alkaline  therapy.  The 
administration  of  thyroid  substance  to  diabetics  often  causes  a 
rise  of  blood-pressure  (Biedl). 

Gout. — lentil  the  pathogenesis  of  gout  is  more  definitely  eluci- 
dated it  is  impossible  to  make  positive  statements  in  regard  to 
the  relation  of  this  disease  to  arterial  hypertension.  It  seems  that 
the  products  of  protein  metabolism,  if  increased  or  abnormal  in 
character  owing  to  overeating,  suboxidation,  or  faulty  excretion, 
may  produce  hypertension.  Occasionally  metabolic  intoxication 
seems  to  lead  to  hypotension.  High  pressure  is,  of  course,  the  rule, 
with  added  increments  of  tension  during  the  acute  attacks  (pain), 
but  gout  is  very  commonly  associated  with  arteriosclerosis  and 
chronic  nephritis.  The  latter  certainly  accounts  for  a  measure, 
if  not  all,  of  the  increased  blood-pressure.  Hypotension  is  some- 
times seen  in  the  later  stages  in  association  with  cachexia,  acidosis, 
and  cardiac  weakness.  It  has  also  been  described  as  occurring 
at  the  onset  of  an  acute  attack.  The  presence  of  hypertension 
may  be  of  some  value  in  diagnosticating  between  lesions  of   the 

'  Ehrmann,  R.:  Ueber  cardiovasculare  Symptome  u.  d.  Therap.  bei  diabetischem 
Coma  u.  Praecoma.  Berlin  klin.  Wchnschr.,  1913,  1,  11,  1423. 

'  Metabolism  in  Severe  Diabetes,  Carnegie  Institute  of  Washington,  1912,  Pub. 
176,  p.  85. 


364     METABOLIC  DISEASES  AND  MISCELLANEOUS  CONDITIONS 

joints,  skin,  eye,  etc.,  as  to  whether  they  be  tuberculous  or  gouty 
in  origin. 

Experimental  Data. — Investigations  point  strongly  to  the  conclu- 
sion that  the  occurrence  of  gouty  symptoms  is  closely  associated 
with  abnormalities  of  protein'  metabolism,  expecially  with  that 
portion  of  it  which  relates  to  the  breaking  down  and  elimination 
of  the  amino-acids. 

In  animals  the  intravenous  injection  of  guanin  (0.02  to  0.03  gm. 
per  kilo)  causes  a  fall  of  blood-pressure  of  from  2.4  to  4  c.c.  Hg.  If 
other  substances  are  employed  which  stand  chemically  near  to 
guanin  but  have  no  amino  group,  e.  g.,  xanthin,  uric  acid,  an  increase 
of  pressure  results  (0.7  to  2.6  cm.  Hg.).  In  the  transition  from 
guanin  to  uric  acid  there  is  a  splitting  off  of  the  animo  group,  to 
which  guanin  probably  owes  its  pressor  effect.^ 

Jaundice, — Jaundice  is  often  associated  with  hypotension. 
According  to  Federn,  the  latter  can  often  be  demonstrated  before 
the  bile  appears  in  the  urine. 

Experivientally  a  small  amount  of  bile  in  the  blood  depresses 
cardiac  contractility  and  slows  the  rate.  Large  quantities  increase 
contractility  but  shorten  diastolic  relaxation.  Paradoxically  it 
would  seem,  these  changes  are  more  pronounced  when  the  heart  is 
fatigued  or  diseased.^ 

Addison's  Disease. — Arterial  hypotension  is  frequently  but  not 
invariably  found  in  Addison's  disease.  It  bears  no  relation  to  the 
degree  of  pigmentation,  but  is  believed  to  occur  when  the  medullary 
portion  of  the  adrenal  gland  is  diseased.  This  tends  to  corroborate 
the  belief  generally  held  at  present  that  the  adrenal  secretion  may 
raise  blood-pressure,  but  that  it  is  not  under  normal  conditions 
the  sole  cause  of  its  maintenance,^  and  further,  that  Addison's 
disease  results  not  merely  from  degeneration  of  the  adrenal  glands 
but  from  involvement  of  the  entire  chromaffin  system. 

Grunbaum  found  the  oral  administration  of  epinephrin,  while 
it  did  not  raise  blood-pressure  in  health,  did  so  in  case  of  adrenal 
insufficiency.  He  suggests  the  use  of  this  substance  as  a  diagnostic 
test.  Together  with  careful  blood-pressure  readings,  three  grains 
of  adrenalin  are  administered  thrice  daily.    Any  distinct  subsequent 

'  Degres  and  Dorleans:  Influence  de  la  constitution  des  corps  purques  sur  leur 
action  vis-a-vis  de  la  pression  art6rielle,  Compt.  rend.  Acad,  des  Sciences,  Paris, 
1913,  clvi,  93. 

'  Berti,  A. :     Colemia  Sperimentale,  Gaz.  d.  Osped.  e.  d.  Cliniche,  1916,  xxxvii,  1236. 

'  Hoskins,  R.  G.,  and  Rowley,  W.  N.:  The  Effects  of  Epinephrin  Infusion  on 
Vasomotor  Irritability,  Am.  Jour.  Physiol.,  1915,  xxxvii,  471.  Cannon,  W.  B. : 
Bodily  Changes  in  Pain,  Hunger,  Fear,  Rage,  New  York,  1913. 


AUTO-INTOXICATION  365 

rise  of  pressure  in  the  absence  of  a  valvular  lesion  is,  he  believes 
suggestive  of  Addison's  disease  even  in  the  absence  of  asthenia  and 
pigmentation.  Too  much  reliance  must  not  be  placed  upon  this 
test. 

On  the  other  hand,  recent  experiments  have  shown  that  a  fall 
of  pressure  occurs  after  the  injection  of  dilute  solutions  of  epinephrin, 
and  that  hypertension  occurs  only  when  abnormally  large  doses 
are  used.  In  amounts  sufficient  to  raise  blood-pressure,  intestinal 
peristalsis  is  completely  inhibited.  If  these  observations  are  cor- 
rect the  low  pressure  seen  in  adrenal  insufficiency  and  in  Addison's 
disease  are  probably  due  rather  to  an  interference  with  muscular 
metabolism,  including  that  of  the  heart  and  the  arteries,  than  to 
failure  of  a  normal  tonic  stimulation  of  the  sjyinpathetic  nervous 
system.  1 

Auto-intoxication. — iVIuch  has  been  written  and  but  little  is 
known  regarding  gastro-intestinal  auto-intoxication.  The  literature 
on  the  subject  is  enormous  and  concerns  itself  mainly  in  nebulous 
hypothecation.  It  has  been  shown  that  two  pressor  bases  may 
be  extracted  from  putrid  meat,  and  the  assumption  that  they 
are  generated  in  the  intestine  through  bacterial  action  seems 
probable.  Granger  was  unable  to  confirm  the  observation  of 
Abelous  and  Bain  that  the  normal  urine  contains  pressor  bases, 
and  there  is  as  yet  no  definite  clinical  proof  that  these  urinary 
pressor  substances  are  identical  with  those  isolated  from  decaying 
proteids.2 

Hydroxyphenylethylamin  is  a  substance  which  can  be  prepared 
from  tyrosin,  a  derivative  of  protein  cleavage,  by  splitting  off 
carbon  dioxide  from  the  tyrosin  molecule.  This  reaction  may  be 
caused  by  putrefactive  bacteria.  Hydroxyphenylethylamin  has 
been  isolated  by  Barger^  from  putrefying  proteids  and  shown 
to  have  a  pressor  action.  The  group  of  aromatic  amins  to  which 
it  belongs  is  related  chemically  to  epinephrin.  It  is  an  interesting 
fact  that  this  aromatic  am  in  (p-hydroxyethylamin)  with  its  blood- 
pressure-raising  qualities  is  found  in  epinephrin,  in  ergot,  and  as 
the  result  of  bacterial  putrefaction.  "Our  poisons  and  our  drugs 
are  in  many  instances  the  close  relatives  of  harmful  compounds  that 

1  Hoskins  and  McClure:  Am.  Jour.  Phys.,  1912,  xxi,  59.  Hoskins  and  McPeck: 
The  Effect  of  Adrenal  Massage  in  Blood-pressure,  Jour.  Am.  Med.  Assn.,  1913, 
Ix,   1777. 

*  Granger,  A.  S.:  Concerning  the  Presence  in  the  Urine  of  Certain  Pressor  Bases, 
Arch.  Int.  Med.,  1912,  x,  202. 

'  The  Isolation  of  Pressor  Principles  of  Putrid  Meat,  Jour.  Physiol.,  1908,  xxxviii, 
341. 


366     METABOLIC  DISEASES  AND  MISCELLANEOUS  CONDITIONS 

represent  the  intermediary  steps  in  the  daily  routine  of  metabolism." 
As  AbeF  has  recently  stated,  "It  would  appear  that  we  have  at 
last  got  onto  the  right  road  for  the  chemical  investigation  of  alimen- 
tary toxemia  and  its  alleged  consequences,  such  as  arteriosclerosis 
and  chronic  renal  disease.  Phenylalanine,  tyrosin,  tryptophane  and 
histidine,  the  harmless  precursors  of  toxic  amins  are  always  present 
in  the  intestine,  and  when  they  are  acted  upon  by  an  excessive 
number  of  certain  microorganisms  the  resulting  toxic  bases  will 
surely  be  formed  in  excess.  If  they  are  then  taken  up  into  the  blood 
in  quantities  too  large  for  transformation  by  the  liver  or  other 
defensive  organs,  into  harmless  derivations,  they  must  inevitably 
manifest  their  pharmacological  and  toxicological  properties." 

Not  only  arterial  hypertension  but  also  hypotension  has  been 
clinically  attributed  to  alimentary  toxemia.  That  the  latter  no 
less  than  the  former  may  have  basis  in  fact  is  shown  by  the 
observation  of  Barger  and  Dale^  who  were  able  to  obtain  a  highly 
toxic  depressor  base — B-amino-azolylethylamin  from  the  intestinal 
mucosa. 

This  substance  appears  to  be  formed  from  histidine  through  the 
agency  of  the  B-aminophilus  intestinalis.^  It  has  further  been 
suggested  that  the  toxic  substance  which  causes  anaphylactic 
shock  bears  an  allied  chemical  composition. 

The  Effects  of  Glandular  and  Tissue  Extracts. — The  extracts 
of  most  animal  tissues  when  injected  intravenously  lower  blood- 
pressure.  It  has  been  suggested  that  in  many  instances  this 
depressor  action  is  due  to  cholin,  a  substance  abundantly  found  in 
brain-tissue  extracts  and  in  tissues  in  which  proteolytic  changes, 
which  occur  very  early,  have  taken  place.  The  action  of  cholin 
is  characterized  by  the  fact  that  the  first  injection  fails  to  establish 
tolerance  to  a  second  injection,  and  by  the  fact  that  the  reaction 
may  be  counteracted  by  atropin.  The  depressor  effects  of  peptone 
have  long  been  known,  but  in  this  case  tolerance  is  established 
by  the  first  dose*  (see  Toxic  Shock,  page  219). 

.Certain  glandular  extracts  have  also  been  shown  to  possess  a 
specific  action  on  blood-pressure.  Thus  extract  of  the  adrenals 
and  hypophysis  possess  well-marked  pressor  effects,  while  pineal 
and  thyroid  extracts  cause  a  fall  of  pressure. 

*  The  Blood  and  the  Specific  Secretory  Products  of  the  Organs  of  Internal  Secre- 
tion, Science,  1915,  N.  S.,  xlii,  165. 

«  Jour.  Physiol.,  1910,  xl,  38. 

'  Berthelot  and  Bertrand:   Compt.  rend,  de  I'Acad.  d.  Sciences,  1826,  cliv,  1643. 

'' Sanford  and  Blackford:  Comparative  Study  of  the  Effects  on  Blood-pressure 
of  the  Extracts  and  Serums  of  Exophthalmic  Goitre  and  other  Substances,  Jour.  Am. 
Med.  Assn.,  1914,  Ixii,  117  (bibliography). 


EXOPHTHALMIC  GOITRE  367 

Acromegaly. — ^In  acromegaly  pressure  is  variable  (see  Pituitary 
Extract,  page  352).  Chromic  hypopituitarism,  both  clinical  and 
experimental,  is  characterized  by  a  deposition  of  fat,  a  lowering  of 
body  temperature,  a  retardation  of  the  pulse  and  respiratory 
rates,  somnolence  and  lowered  blood-pressure.  These  symptoms, 
as  has  been  pointed  out  by  Gushing  and  Goetch,^  bear  a  striking 
resemblance  to  the  state  of  hibernation  as  it  occurs  in  some  animals. 
W.  Landon  Brown'^  states  that  in  the  early  stages  of  acromegaly 
in  association  with  hemianopia,  lowered  sugar  tolerance  and  osseous 
hypertrophy,  blood-pressure  is  high,  whereas  in  the  later  stages 
with  a  high  sugar  tolerance  blood-pressure  is  low.  In  Frolich's 
syndrome  (primary  hypopituitarism)  smooth,  dry  skin,  scant  pubic 
and  axillary  hair,  small,  thin  finger-nails — blood-pressure  is  low. 

Exophthalmic  Goitre. — Experimental  Data. — In  1894  Oliver  and 
Schafer  reported  that  the  intravenous  injection  of  aqueous  or 
glycerinized  extracts  of  the  thyroid  gland  produced  a  fall  of  blood- 
pressure  in  which  the  heart  took  no  part.  These  observations 
have  been  widely  corroborated.  A  few  observers  found  an  increased 
pressure  and  local  vascular  constriction  after  thyroid  injections. 
The  pulse  rate  has  been  reported  both  as  accelerated  and  retarded. 

Von  Gyon  and  Oswald  found  lowering  of  pressure  and  slowing 
of  the  pulse  after  the  intravenous  injection  of  iodo thyroid  even 
after  atropinization  and  section  of  the  vagi.  Later  experiments 
have  shown  that  the  effect  of  this  substance  upon  cardiac  inhibition 
is  questionable,  and  that  the  fall  of  pressure  is  not  a  specific  action, 
but  occurs  after  the  injection  of  many  organic  extracts  which 
contain  cholin,  a  substance  which  is  associated  with  the  metabolism 
of  lecithin  and  other  lipoids,  and  to  which  the  fall  of  blood-pressure 
is  due.  On  the  other  hand,  it  has  been  maintained  that  the  fall  of 
pressure  is  not  due  to  a  cholin  but  to  a  specific  substance,  vaso- 
dilatonin  (Popielski),  which  acts  even  after  atropinization.  This 
substance  seems  not  to  be  a  specific  thyroid  product.  In  contra- 
distinction to  the  equivocal  results  in  dogs  and  rabbits,  in  cats 
iodothyroid  produces  a  marked  lowering  of  blood-pressure  which 
is  due  to  both  vascular  and  cardiac  action;  but  here  again  it  seem? 
that  similar  effects  may  be  produced  by  other  iodized  albumins. 
Therefore  the  contention  of  von  Gyon  that  iodothyroid  possesses 
a  fundamental  cardiovascular  regulatory  function  has  not  been 
substantiated,  nor  has  the  hypothesis  that  the  cerebral  circulation 
is  controlled  by  an  interaction  between  the  thyroid,  hypophysis, 

1  Jour.  Exp.  Med.,  1915,  xxii,  No.  1. 

^Physiological  Principles  in  Treatment,' London, ^1914,^p.  34. 


368     METABOLIC  DISEASES  AND  MISCELLANEOUS  CONDITIONS 

and  pineal  glands  any  better  foundation.  The  intravenous  injection 
of  thyroid  extract  in  cats  and  rabbits  increases  the  stimulability 
of  the  depressor  function  and  the  rise  of  pressure  produced  by 
adrenalin  (Biedl).^  More  recently  Kendal  has  isolated  a  crystalline 
compound — alpha  iodin — whidh  appears  to  be  the  active  constit- 
uent of  thyroidal  secretion.  He  has  made  some  interesting  obser- 
vations regarding  its  effect  on  the  circulation.  For  several  hours 
after  its  administration  no  effect  upon  blood-pressure  or  pulse  rate 
is  noted,  but  if  amino-acids  are  simultaneously  injected  the  pulse 
rate  is  enormously  increased.  It  would  seem  that  the  increased 
pulse  rate  is  a  response  to  the  demands  of  greatly  stimulated 
metabolism. 2 

The  oral  administration  of  thyroid  substance  in  man  produces 
an  increased  pulse  rate  and  often  a  fall  of  blood-pressure;  in 
diabetics  a  rise  of  pressure  occurs  which  outlasts  the  emploxinent 
of  the  medication  by  several  days.  The  prolonged  use  of  thyroid 
usually  produces  similar  effects,  although  both  experimentally  and 
therapeutically  the  results  are  inconstant  and  have  again  been 
explained  as  not  due  to  specific  thyroidal  action  (Biedl).  Blackford 
and  Sanford  found  that  a  powerful  depressor  substance  exists  in 
exophthalmic  goitre  cases  and  that  a  primary  injection  establishes 
tolerance  to  the  action  of  any  further  administration.  Atropin 
does  not  inhibit  its  action,  but  heating  to  70°  C.  does,  hence  the 
substance  does  not  behave  physiologically  like  cholin.  The  action 
is  chiefly  the  result  of  peripheral  vasodilatation  associated  with 
some  diminution  of  the  systolic  output.  Irritability  of  the  vagus 
is  not  decreased.  The  existence  of  a  crossed  tolerance  between 
the  depressor  action  of  extract  of  exophthalmic  goitre  and  of  serum 
from  patients  suffering  from  this  disease  suggests  that  the  two 
substances  are  identical.^ 

Clinical  Data. — The  earlier  reports  of  blood-pressure  findings  in 
exophthalmic  goitre  are  very  variable,  some  observers  having  noted 
hypertension,  while  others  found  hypotension  or  normal  pressures. 
T)iis  is  largely  due  to  the  fact  that  only  the  systolic  pressure  was 
es>timated.  More  recent  investigations  by  Plummer  and  by  Taussig 
have  shown  that  in  toxic  goitre  the  systolic  pressure  is  usually 
increased  while  the  diastolic  pressure  remains  normal.  Thus  the 
pnhe-'pressnre  is  large. 

>  Innere  Sekretion,  1913,  i,  205. 

*  Kendall,  E.  C. :  Recent  Advances  in  Our  Knowledge  of  the  Active  Constituent  in 
the  Thyroid.  Its  CUnical  Nature  and  Function,  Boston  Med.  and  Surg.  Jour., 
October  19,  1916,  clxxv. 

'  Blackford,  J.  M.,  and  Sanford,  M.  D.:  Med.  Record,  1913,  Ixxiv,  379. 


EXOPHTHALMIC  GOITRE  369 

The  clinical  picture  of  toxic  goitre  has  much  in  common  with 
that  of  aortic  insufficiency.  Increased  pulse  rate,  pulsus  celer, 
capillary  pulse,  throbbing  arteries,  cardiac  hypertrophy,  arterial 
sounds  and  the  persistence  of  the  fifth  auscultatory  phase,  are 
common  to  both  conditions.  In  addition  Taussig^  has  shown  that 
differences  in  the  arm  and  leg  pressures  affecting  the  systolic  and 
the  pulse-pressure  occur  quite  uniformly  in  toxic  goitre.  The  pop- 
liteal pressure  in  recumbency  is  higher  than  that  in  the  brachial 
arteries.  This  is  in  marked  contrast  to  the  findings  in  non-toxic 
goitres  in  which  the  pressures  in  the  upper  and  lower  extremities 
are  strikingly  identical.  The  incessant  pounding  to  which  the 
arteries  in  toxic  goitre  are  subjected  leads  to  sclerotic  changes,  and 
Plummer  believes  that  these  cases  in  time  develop  chronic  arterial 
hypertension. 

Average  Blood-pressure  by  Hale^decades;  Non-hyperplastic  Goitre. 

(Plummer.) 

Number  of  Average  systolic         Average  diastolic 

Years.  cases.  blood-pressure.  blood-pressure. 

10  to  15 15  118.5  72.5 

15  to  20 63  120.7  77.7 

20  to  25 128  123.1  80.2 

25  to  30 190  123.8  80.5 

30  to  35 235  126.9  81.2 

35  to  40  .      .      .      .      .      .  253  134.9  83.6 

40  to  45 246  136.4  85.2 

45  to  50 214  145.8  87.3 

50  to  65 204          /  150.2  87.1 

55  to  60 131  152.6  87.5 

60  to  65  .                  ...  47  160.7  88.6 

65  to  70 13  164.6  83.3 

70  to  75 4  166.2  87.5 

75  to  80 2  106.0  65.0 


Average  Blood-pressure  by  Half-decades;  HYPERPiiASirc  Goitre. 
(Plummer.) 

Number  of             Average  systolic  .\verage  diastolic 

Years.                                            cases.  blood-pressure.  blood-pressure. 

10  to  15 14  138.5  68.8 

15  to  20 58  139.4  75.9 

20  to  25 110  137.8  70.7 

25  to  30 164  139.6  75.2 

30  to  35 139  140.8  78.7 

35  to  40 106  155.2  75.6 

40  to  45 93  145.1  76.7 

45  to  50 94  153.1  77.8 

50  to  55 47  152.4  77.0 

55  to  60 17  160.6  77.7 

60  to  65 5  160.0  71.2 


1  Some  Blood-pressure  Phenomena  in  Exophthalmic  Goitre,  Tr.  Assn.  Am.  Phya 
1916,  xxxi,  121. 
24 


370     METABOLIC  DISEASES  AND  MISCELLANEOUS  CONDITIONS 

Percentage  of  Cases  over  Forty  Years  of  Age  Having  High  Blood- 
pressure.     (Plummer.) 


Systolic  blood- 

Systolic  blood- 

Number  of 

pressure  above 

pressure  above 

cases. 

150. 

160. 

Hyperplastic  goitre     . 

.      117 

47 

34 

Non-hyperplastic  goitre    . 

..      417 

35 

27 

Cholecystitis  with  stones 

.      289 

18 

Uterine  myoma      .... 

.      100 

25 

15 

Positive  Wassermann 

.      100 

21 

14 

Showing  Percentage  of  Cases  by  Decades,  Having  a  Blood-pressure 
Above  160.     (Plummer.) 


Age, 
10  to  20 

Age, 
20  to  30 

Age, 
30  to  40 

Age, 
40  to  50 

Age, 
50  to  60 

Age, 
60  to  70 

years, 
per  cent. 

years, 
per  cent. 

years, 
per  cent. 

years, 
per  cent. 

years, 
per  cent. 

years, 
per  cent 

Hyperplastic  goitre       .      12 

17 

22 

30 

37 

30 

Non-hyperplastic  goitre       1 

2 

7 

21 

31 

20 

The  preceding  tables  taken  from  Plummer's^  publication  show  the 
systolic  and  diastolic  readings  obtained  from  a  large  series  of  goitre 
cases.  It  is  evident  from  the  diastolic  pressures  that  there  was 
no  vascular  hypertension  in  these  cases. 

Plummer  construes  the  high  systolic  pressure  as  an  effort  to  main- 
tain a  normal  diastolic  pressure  despite  widely  dilated  arterioles, 
by  an  increased  systolic  output  ar^d  an  accelerated  rate.  In  other 
words,  the  ynlse-j)ressure  is  large  and  the  diastolic  pressure  remains 
normal  because  even  the  widely  opened  arterioles  cannot  with 
sufficient  rapidity  carry  off  the  tremendous  cardiac  output.  He 
further  believes  that  in  exophthalmic  goitre  the  height  of  the  sys- 
tolic pressure  is  an  expression  of  the  degree  of  intoxication.  This 
intoxication  which  causes  the  high  systolic  pressure  although  often 
transitory,  later  leads  to  diastolic  hypertension  and  in  time  to 
permanent  cardiovascular  changes. 

As  might  be  expected  from  the  symptoms  of  this  disease,  flushing, 
warmth,  perspiration,  and  a  rapid  pulse,  blood  flow  is  rapid.  Stewart 
found  in  a  case  studied  by  him  that  immersion  of  one  hand  in  cold 
water  reduced  the  flow  in  its  fellow  from  14  to  7  gm.  per  100  c.c. 
per  minute.  Weber  found  that  in  exophthalmic  goitre  and  in  neuras- 
thenia there  was  a  tendency  for  the  normal  vasomotor  reflexes 
associated  with  attention  and  the  suggestion  of  movement  to  be 
readily  lessened  or  even  reversed.  In  other  words,  fatigue  phe- 
nomena occurred  more  readily  than  in  normal  cases. 

McCrea  has  called  attention  to  a  special  type  of  exophthalmic 
goitre  associated  with  a  gain  in  weight,  an  increased  blood-pressure 

*  Blood-pressure  and  Thyrotoxicosis,  Tr.  Assn.  Am.  Phys.,  1915,  xxx,  450. 


STATUS  LYMPHATICUS  371 

(200),  a  high  lymphocytosis  and  drowsiness.  Improvement  occurs 
under  the  use  of  thymus  extract. 

Kaess^  found  the  viscosity  of  the  blood  in  exophthalmic  goitre 
normal  in  19  per  cent.,  decreased  in  50  per  cent.,  and  increased  in 
31  per  cent,  of  his  cases.  The  latter  occurred  in  the  vagotonic  cases 
and  probably  resulted  from  increased  perspiration,  diarrhea,  etc. 
Diminished  viscosity  occurred  in  the  sympathicotonic  cases  and 
was  perhaps  due  to  abnormality  of  the  serum.  Hemic  viscosity, 
however,  bears  no  constant  relation  to  blood-pressure. 

Myasthenia  Gravis. — ^In  a  case  reported  by  Bookman  and 
Epstein,  and  associated  with  cutaneous  bronzing,  the  systolic  blood- 
pressure  ranged  between  215  and  190;  the  diastolic  pressure  between 
170  and  140  mm.^ 

Periarteritis  Nodosa. — Although  Meyer,  in  1878,  believed  that 
this  disease  was  due  to  high  blood-pressure  which  caused  a  rupture 
of  the  arterial  media,  recent  investigations  point  to  an  infectious 
origin.  In  5  of  the  38  cases  of  this  disease  collected  by  Lamb^  the 
blood-pressure  readings  were  reported  as  140,  215,  77-100,  130-165, 
104,  therefore  showing  no  constant  relationship. 

Myxedema. — In  myxedema  blood-pressure  is  generally  increased. 

Adiposity. — Adiposity  is  not  associated  with  any  constant  blood- 
pressure  abnormalities.  When  the  circulatory  system  is  normal 
a  loss  of  weight  entails  no  fall  of  pressure,  but  if  hypertension  is 
associated  with  adiposity  a  reduction  of  weight  produces  a  fall  of 
pressure,*  largely,  it  would  seem,  owing  to  a  diminution  of  metabolic 
waste  products  which  result  from  overeating.     (See  p.  278.) 

Scurvy. — The  Capillary  Resistance  Test. — In  the  early  stages  of 
scorbutus,  even  before  other  clinical  manifestations  have  occurred, 
a  cuff  applied  to  the  arm  and  kept  inflated  for  three  minutes  will 
cause  the  appearance  of  petechial  spots.^  The  test  is  of  course 
not  specific  for  scurvy  but  merely  indicates  the  resistance  of  the 
capillaries  to  pressure. 

Status  Lsmiphaticus. — ^In  status  lymphaticus  we  have  to  do  with 
an  individual  who  is  constitutionally  subnormal.  The  muscular 
physique  is  poor  and  the  physical  strength  and  constitutional 
resistance  below  the  normal  standard.  The  blood-pressure  is  apt 
to  be  somewhat  lower  than  the  subject's  age  and  weight  would 

>  Bruns:     Beitr.  z.  klin.  Chir.,  1912,  Ixxxii,  253. 

2  Bookman  and  Epstein:  Metabolism  in  a  Case  of  Myasthenia  Gravis,  Am.  Jour. 
Med.  Sc.  1916,  cli,  267. 

*  Periarteritis  Nodosa,  Arch.  Int.  Med.,  1914,  xiv,  481. 

*  Dunin,  Th.:  Der  Blutdruck  in  Verlaufe  d.  Arteriosclerose,  Ztschr.  f.  klin.  Med., 
1904.  vol.  liv. 

*  Hess  and  Fish:     Infantile  Scurvy,  Am.  Jour.  Child.  Dis.,  1914,  viii,  No.  5. 


372     METABOLIC  DISEASES  AND  MISCELLANEOUS  CONDITIONS 

lead  us  to  expect.  According  to  Muenzer  hypotension  is  found 
associated  with  lymphocytosis.  While  this  may  hold  good  for 
extreme  cases,  certainly  lymphocytosis  has  not  been  shown  to  be 
a  constant  phenomenon  in  adults,  not,  so  far  as  we  are  aware,  in 
children.  Operative  procedures  in  this  class  of  cases  are  dangerous, 
especially  if  chloroform  is  used  as  an  anesthetic.  The  toxemia  of 
acute  infectious  disease  is  also  badly  borne  by  these  patients. 
Sudden  and  unexpected  death  during  anesthesia,  infections,  while 
swimming,  or  in  children  while  quietly  resting  in  bed,  appears  to 
bear  a  relation  to  enlargement  of  the  thymus  gland.  The  experi- 
mental intravenous  injection  of  thymus  substance  lowers  blood- 
pressure,  but  whether  this  results  from  vasomotor  depression  or 
from  purely  mechanical  causes  (embolism,  thrombosis),  as  suggested 
by  Popper,^  is  uncertain.  It  may  also  be  simply  the  non-specific 
fall  of  pressure  which  attends  the  intravenous  introduction  of 
different  foreign  proteids. 

Anemia. — Experimental  Data. — Loss  of  blood  tends  to  cause  a 
fall  of  blood-pressure.  When  hemorrhage  has  been  moderate  this 
tendency  is  compensated  by  reflex  vasomotor  constriction  and  an 
increased  pulse  rate;  when  excessive,  death  occurs  with  a  progres- 
sive fall  of  pressure,  owing  to  cerebral  anemia. 

The  quality  of  the  blood  exerts  an  influence  on  vascular  tonus 
and  blood-pressure.  Lesser  found  that  section  of  the  cord  between 
the  second  and  fourth  cervical  vertebrae  caused  a  fall  of  pressure 
and  a  diminution  of  hemoglobin  in  the  large  vessels,  whereas 
stimulation  of  the  sectioned  cord  increased  the  hemoglobin.  Section 
above  the  splanchnic  centre  diminishes  the  erythrocytes  (Cohnheim 
and  Zuntz).  Experimental  epinephrin  hypertension  (in  dogs) 
increases  the  red  cells  in  the  capillaries  and  veins  but  not  in  the 
large  arteries.  According  to  Erb  the  arterial  and  venous  hemic 
concentration  increases  with  a  rise  and  decreases  with  a  fall  of 
pressure.  Holobuts  attributes  the  variations  of  the  number  of 
erythrocytes  to  changes  in  the  volume  of  the  corpuscles.  The 
dried  residue  and  the  plasma  show  but  little  change  with  pressure 
variations  (Horner)  .^ 

Clinical  Data. — Blood-pressure  observations  in  the  different  forms 
of  anemia  are  of  little  value,  except  in  the  detection  of  nephritic 
complications.  If  the  anemia  is  marked,  pressure  will  be  low  in 
proportion  to  the  cachexia  and  general  weakness.     Chlorosis  is 

1  Ueber  d.  Wirkung  d.  Thymus  extrakts,  Sitzungsber.  d.  k.  Akad.  d.  Wissensch., 
1905,  cxiv. 

«  Der  Blutdruck  d.  Menschen,  Vienna,  1913,  p.  101. 


EFFECTS  OF  HIGH  ALTITUDES  ON  BLOOD-PRESSURE     373 

said  to  be  accompanied  by  slight  hypertension  in  the  early  stages, 
followed  later,  if  its  course  be  prolonged  or  severe,  by  hypotension. 
Blood-pressure  bears  no  constant  relation  to  either  the  percentage 
of  hemoglobin  or  to  the  total  number  of  corpuscles.  According  to 
Plesch  the  minute  volume  of  the  heart  is  increased  in  the  anemias. 
Stewart  found  peripheral  blood  flow  in  anemia  less  than  normal. 
This  peripheral  constriction  has  been  construed  as  a  necessary 
compensatory  arrangement  for  increasing  blood  flow  through  the 
lungs.  The  deficiency  in  the  hand  flow  is  less  in  chlorotic  anemia 
than  in  the  other  forms.  Muenzer'  found  lymphocytosis  frequently 
associated  with  arterial  hypotension.  In  pernicious  anemia  very 
low  readings  are  often  observed.  Cabot  states  that  systolic  pressures 
of  80  and  even  60  mm.  are  not  unusual. 

Cachexia. — Nutritional  failure  from  whatever  cause  is  often 
associated  with  low  arterial  pressure,  but  this  is  by  no  means 
invariably  the  case.  The  high  pressures  of  nephritis  may  be  some- 
what reduced  by  the  coincident  presence  of  cachexia.  A  remarkable 
case  of  persistent  hypotension  has  been  reported  by  Rolleston:^ 
that  of  a  man  with  carcinoma  of  the  tongue  and  amyloid  disease 
who  managed  to  live  for  several  weeks  with  systolic  and  diastolic 
pressures  of  70  and  35  respectively. 

The  Effects  of  High  Altitudes  on  Blood-pressure. — The  disturb- 
ances of  physiological  function  which  result  from  high  altitudes  are 
mainly  due  to  a  deficiency  of  oxygen.  The  vertigo,  confusion  of 
the  senses,  and  fatigue  can  be  abated  by  the  inhalation  of  oxygen. 
At  altitudes  of  from  4000  to  8000  meters  (13,000-26,000  feet) 
no  special  precautions  are  necessary,  provided  the  partial  pressure 
of  the  oxygen  in  the  lungs  is  raised.  Beyond  this  special  devices 
insuring  adequate  oxygenation  must  be  employed.  Mountain 
sickness  results  from  a  combination  of  diminished  oxygen  supply 
associated  with  muscular  exertion,  producing  syncope,  a  weak 
pulse,  and  other  symptoms  of  cerebral  anemia.  Circulatory  symp- 
toms are  especially  apt  to  occur  in  aviators  if  very  rapid  ascents  or 
descents  are  made. 

Henderson's  studies  made  on  Pike's  Peak  (14,000  feet)  showed 
that  there  was  a  slight  fall  of  arterial  pressure.  It  seems  to  be 
generally  agreed  that  altitude  of  a  considerable  degree  does  tend 
to  lower  blood-pressure  and  to  increase  the  pulse  rate,  and  that 
these  changes  are  more  marked  at  first,  i.  e.,  before  "  acclimatiza- 

1  Blutdruck  u.  Blutbild,  Med.  Klinik,  1913.  ix,  2028,  2074. 

'  Low  Blood-pressure  in  Carcinoma  of  the  Tongue  with  Amyloid  Disease,  Lancet, 
September  12,  1914,  p.  692, 


374    METABOLIC  DISEASES  AND  MISCELLANEOUS  CONDITIONS 

tion"  has  taken  place.  Such  a  fall  of  pressure  may  range  between 
1  and  22  mm.,  and  the  effects  are  naturally  more  marked  in  hypo- 
tensive individuals.  There  is,  however,  a  great  difference  in  indi- 
vidual susceptibility.  The  systolic  pressure  is  chiefly  and  more 
constantly  affected,  and  diastolic  pressure  may  even  rise.  Ordinarily 
slight  elevations  produce  but  little  change  in  blood-pressure.  It 
is  quite  impossible  either  from  a  man's  general  physique  or  from 
any  other  criterion  to  forecast  how  much  his  pressure  may  be 
affected.^  The  rate  of  hlood  flow  was  increased  from  30  to  76  per 
cent.,  by  residence  at  Pike's  Peak  (14,000  feet) .  This  was  associated 
in  part  with  an  increased  pulse  rate  and  a  fall  of  venous  pressure. 
The  arterial  pressure  was  not  clearly  altered  either  by  altitude  or 
by  oxygen  inhalations.  The  latter  did  slow  the  pulse  rate  14  per 
cent,  at  14,109  feet,  and  54  per  cent.,  at  6000  feet.^  All  three  of 
these  factors  are  more  increased  by  exercise  than  at  lower  levels. 
Furthermore,  the  stimulating  effect  of  the  low  barometric  pressure 
is  more  marked,  the  more  vigorous  the  exercise,  because  although 
pulse  and  arterial  pressure  increase  the  venous  pressure  rarely 
exceeds  the  normal  for  low  altitudes.  A  short  sprint  increased  the 
systolic  pressure  on  an  average  61  mm.  (Schneider).  The  pulse 
rate  remains  high  for  a  longer  time  after  cessation  from  work  and 
the  period  of  postexercise  subnormal  systolic  pressure  is  increased. 
In  brief,  exercise  at  high  altitudes  is  much  more  taxing  upon  the 
circulatory  apparatus  than  at  lower  levels,  and  hence  the  danger 
of  permanent  as  well  as  immediate  damage  is  especially  to  be 
considered  by  (1)  the  unacclimated;  (2)  the  non-robust,  and  (3) 
individuals  who  have  cardiovascular  lesions.^  The  readings  obtained 
by  Clough  at  an  elevation  of  over  5000  feet  were  practically  iden- 
tical with  those  taken  at  the  sea  level.  Miners  in  suddenly  descend- 
ing or  ascending  1700  feet  to  and  from  their  work  show  variations 
hardly  exceeding  5  mm.  Hg.*  Hess^  has  attempted  to  explain 
the  changes  in  blood-pressure  at  high  altitudes  by  the  fact  that 
the  normal  balance  between  the  concentration  of  the  arterial  and 
the  venous  blood  (which  he  believes  is  normally  regulated  by  the 
lungs)  is  upset. 

'  Schneider  and  Hedblom:  Blood-pressure,  with  Special  Reference  to  High  Alti- 
tudes, Am.  Jour.  Physiol.,  1908,  xxiii,  90. 

2  Schneider,  E.  E.,  and  Sisco,  D.  L.:  Circulation  of  the  Blood  at  High  Altitudes, 
Am.  Jour.  Physiol.,  1914,  xxxiv,  1  (literature). 

'  Schneider,  Cheley  and  Sisco:    Am.  Jour.  Physiol.,  1916,  xl.  No.  3. 

*  Clough,  F.  E. :  Blood-pressure  Variations  as  Influenced  by  Rapid  Changes  in 
Altitude,  Arch.  Int.  Med.,  1913,  xi,  590. 

*  Die  Beeinflussung  d.  Fliissigkeits  anstauches  zw.  Blut.  u.  Geweben  durch 
Schwankungen  d.  Blutdrucks,  Deutsch.  Arch.  f.  klin.  Med.,  1904,  Ixxix,  128. 


EFFECTS  OF  TROPICAL  CLIMATE  375 

Doubtless  many  of  the  contradictory  statements  regarding  the 
effects  of  altitude  on  blood-pressure  are  due  to  the  fact  that  normal 
and  abnormal  subjects  have  been  classed  together.  Thus  among 
tuberculous  patients  an  elevation  of  6000  feet  appears  to  increase 
blood-pressure,  which  on  the  whole  should  have  a  distinctly  bene- 
ficial effect.^  Altitude  has  a  more  pronounced  effect  upon  hyper- 
tension due  to  general  arteriosclerosis  than  upon  that  associated 
with  well-marked  nephritic  lesions^  (see  page  53). 

The  question  as  to  the  effect  of  altitude  upon  the  individual  is 
an  important  and  practical  one.  The  physician  is  constantly  con- 
sulted regarding  the  effects  of  high  altitude  in  tuberculosis,  heart 
disease,  emphysema,  etc.  It  is  generally  agreed  that  residence 
at  a  high  elevation  increases  the  number  of  erythrocytes  and  the 
percentage  of  hemoglobin.  There  is  also  reason  to  believe  that 
the  cells  of  the  pulmonary  alveoli  possess  and  may  take  on  an 
increased  capacity  to  secrete  oxygen  into  the  blood.  These  changes 
are  of  a  compensatory  nature. 

Plungian's  investigations  indicate  that  barometric  changes  at 
a  given  altitude  exercise  an  effect  upon  individual  blood-pressure, 
although  this  is  inconstant,  both  quantitatively  and  qualitatively. 
The  most  marked  changes  generally  occur  in  tuberculous  and 
arteriosclerotic  subjects  after  a  sudden  fall  of  the  barometer.^ 

The  Effects  of  Tropical  Climate. — Much  has  been  written  on 
the  effects  of  tropical  sunlight  on  white  men.  To  whatever  the 
deleterious  effects  are  due,  they  are  apparently  not  the  result  of 
blood-pressure  changes.  The  average  blood-pressure  of  Americans 
in  the  Philippines  is  somewhat  lower  than  that  when  at  home.  The 
lowest  readings  are  obtained  during  the  first  three  months  of  tropical 
residence  and  during  the  hottest  months.  No  difference  has  been 
noted  among  individuals  with  light  or  dark  complexions,  nor  when 
different  types  of  underwear  are  worn.*  In  a  study  of  717  Filipinos 
made  by  Conception  and  Bulatao^  it  was  found  that  in  individuals 
averaging  28.5  years  the  average  pressure  for  men  was  -  Vy-,  for 

1  Peters  and  Bullock:  Blood-pressure  Studies  in  Tuberculosis  at  a  High  Altitude, 
Arcb.  Int.  Med.,  1913,  xii,  458. 

*  Schrumpf ,  P.:  Blutdruckuntersuchungen  u.  Energometerstudien  im  Hochge- 
birge  bei  Herz-  u.  Kreislaufstorungen,  Deutsch.  Arch.  f.  klin.  Med.,  1914,  xciii,  466. 

'  Plungian,  M.:  Ueber  d.  Wirkung  athmosphaerischer  Einflusse  auf  d.  Blutdruck, 
Dissert.  Basel,  1913,  p.  43. 

*  Chamberlain,  W.  P. :  A  Study  of  the  Systolic  Blood-pressure  and  the  Pulse 
Rate  of  Healthy  Adult  Males  in  the  Philippines,  Philippine  Jour.  Sc,  1912,  vi,  467. 

'Conception,  I.,  and  Bulatao,  E. :  Blood-pressure  Picture  of  the  Filipinos, 
Philippine  Jour.  Sc,  Sec.  B.,  Trop.  Med.,  1916,  ii,  135. 


376    METABOLIC  DISEASES  AND  MISCELLANEOUS  CONDITIONS 

women  ^jj->  with  a  pulse-pressure  of  36  and  33  mm.,  respectively. 
This  is  distinctly  lower  than  the  usual  pressure  of  the  white  races 
in  temperate  zones  but  similar  to  that  found  among  whites  residing 
in  the  tropics.  This  lowered  pressure  has  been  ascribed  to  dim- 
inished resistance  in  the  arterioles  together  with  increased  activity 
of  the  sweat  glands.  According  to  McCay  the  pressure  of  the 
natives  of  India  is  lower  than  that  which  obtains  in  western  Europe, 
and  yet  arteriosclerosis  is  very  common  among  them.  Possibly  the 
low  protein  diet  and  more  constant  perspiration  may  have  a  bearing 
upon  the  low  pressure.  Oliver's  investigation  showed  that  during 
prolonged  hot  weather  blood-pressure  was  lowered  in  the  brachial 
artery,  but  was  increased  in  the  phalangeal  vessels.^ 

Life  Insurance. — The  importance  of  blood-pressure  examinations 
as  a  means  of  sifting  out  undesirable  "risks"  has  now  become 
generally  recognized  by  life  insurance  companies  and  is  routinely 
required  by  many  of  them.  Statistical  studies  have  shown  that 
blood-pressure  values,  abnormal  in  relation  to  the  age  and  sex 
of  the  individual,  are  definitely  associated  with  a  shortened  expec- 
tancy of  life.  It  would  seem  that  pressures  of  20  mm.  either  below 
or  above  the  normal  standard  require  an  explanation.  As  has 
been  stated  elsewhere,  high , pressures  often  indicate  renal,  and 
low  pressures,  tuberculous  disease. 

Fisher^  has  pointed  out  that  a  pressure  of  150  gives  a  higher 
mortality  than  an  average  risk,  and  an  increase  of  15  per  cent, 
above  the  normal  pressure  for  a  given  age  should  always  excite 
suspicion.  Among  2661  risks  with  an  average  pressure  of  142.43, 
at  the  ages  of  forty  to  sixty,  the  mortality  was  about  the  same  as 
the  average  general  mortality  of  the  company,  but  with  an  average 
pressure  of  152.58  among  525  risks  the  mortality  increased  30  per 
cent,  in  excess  of  the  average.  Among  the  rejected  risks  with  an 
average  pressure  of  161.44  (1970  applicants)  the  mortality  was  190 
per  cent,  of  the  medico-actuarial  table  and  more  than  double  the 
average  mortality  of  the  company.  During  the  interval  of  from 
1907  to  August  1,  1913,  1970  applicants  were  refused  insurance 
solely  on  the  basis  of  a  pressure  of  160  mm.  Hg.  These  cases  but 
for  the  pressure  readings  would  have  been  accepted.  The  con- 
tinued accumulation  of  life  insurance  statistics  will  throw  much 

*  Quoted,  Allbutt:  Diseases  of  the  Arteries,  Including  Angina  Pectoris,  London, 
1915,  i,  181. 

'  The  Diagnostic  Value  of  the  Sphygmomanometer  in  Examinations  for  Life 
Insurance.  Jour.  Am.  Med.  Assn.,  1914,  Ixiii,  1763. 


LIFE  INSURANCE  377 

light  not  only  upon  the  diastolic  pressure  and  upon  hypotension, 
but  also  on  a  large  and  important  class  of  individuals  who  have  only 
slightly  increased  pressure,  who  consider  themselves  in  perfect 
health  and  do  not,  therefore,  come  under  the  observation  of  the 
physician. 

As  a  ready  means  of  calculating  what  a  given  individuaVs  blood- 
pressure  should  be,  Faught  has  suggested  the  following  rule:  Assume 
that  the  normal  systolic  pressure  of  a  person  aged  twenty  years 
is  120  mm.,  and  add  1  mm.  Hg.  for  each  additional  two  years 
of  life. 

The  different  phases  of  blood-pressure  as  applied  to  life  insurance 
have  been  discussed  in  different  chapters  of  this  book.  The  reader 
is  specially  referred  to  Instrumental  Technic,  page  129;  Sources 
of  Error,  page  126;  Physiological  Variations  with  Special  Reference 
to  Age,  page  56 ;  Hypertension  in  Nephritis,  page  276;  Hypotension, 
page  193. 

Infants  and  Children. — Blood-pressure  estimations  in  infancy 
and  early  childhood  are  made  with  difficulty  and  fraught  with 
inaccuracy.  The  psychic  effects  produced  by  the  procedure,  which 
often  result  in  crying  or  struggling,  absolutely  vitiate  the  accuracy 
of  the  readings.  The  arm  is  too  small  to  permit  satisfactory  applica- 
tion of  the  cuff,  hence  the  readings  should  be  taken  on  the  thigh 
and  a  small  cuff  (6.5  cm.)  employed.  As  a  temporary  makeshift 
the  usual  12  cm.  cuff  may  be  folded  in  half.  The  child  will  pay  less 
attention  to  the  cuff  when  it  is  applied  to  the  lower  extremity. 
The  diaper  must  be  loosened.  Auscultation  is  more  satisfactory 
than  palpation.  The  diastolic  pressure  which  is  determinable  with 
difficulty  owing  to  the  small  size  of  the  artery  and  of  the  pulse^ 
pressure,  must  generally  be  estimated  either  by  auscultation  or 
by  means  of  a  Fedde  oscillometer  or  some  similar  device.  In 
childhood  and  youth  the  transmission  of  the  pressure  wave  from 
the  centre  to  the  periphery  behaves  differently  than  in  the  adult. 
In  the  former  the  systolic  pressure  in  the  digital  artery  equals 
that  registered  in  the  brachial,  whereas  in  the  adult,  especially 
in  cases  of  nephritis  and  arteriosclerosis,  the  arterioles  are  tonically 
contracted  as  well  as  less  elastic,  and  the  systolic  brachial  pressure 
is  much  higher  than  that  in  the  digital  arteries.^ 

The  diastolic  pressure  is  relatively  higher  and  the  pulse-pressure 


1  Findlay,  L.:     The  Systolic  Pressure  at  Different  Points  of  the  Circuhition  in  the 
Child  and  the  Adult,  Quart.  Jour.  Med..  1910-11,  iv,  489. 


378    METABOLIC  DISEASES  AND  MISCELLANEOUS  CONDITIONS 

is  about  10  mm.  less  than  in  adults.^  On  the  whole,  blood-pressure 
estimations  are  of  much  less  value  in  children  than  in  adults. 

Normal  Pressure. — Before  birth  blood-pressure  is  higher  in  the 
pulmonic,  than  in  the  systemic  circulation.  The  expansion  of  the 
lungs  promptly  lowers  pulmonary  blood-pressure.  Before  this 
occurrence  most  of  the  blood  passes  from  the  pulmonary  artery 
through  the  ductus  arteriosus  into  the  aorta,  but  afterward,  the 
lowering  of  blood-pressure  which  occurs  in  the  systemic  circulation 
when  the  placental  circulation  is  cut  off,  causes  a  collapse  of  the 
ductus  and  thus  favors  its  closure.  Additional  causative  factors 
may  be  the  equalization  of  pulmonary  and  aortic  pressures  and  the 
muscularity  of  the  ductus.  (Abbott.^)  At  birth  systolic  blood- 
pressure  is  said  to  range  between  35  and  55  mm.  Waking  and 
suckling  cause  a  rise  of  about  15  mm.^ 

Preceding  the  onset  of  puberty  there  is  a  tendency  toward  a 
fall  of  pressure,  during  pubescence  there  is  a  period  of  increased 
pressure  which  is  in  turn  followed  by  a  slight  decrease  after  puberty 
has  been  established  (AUbutt).  (See  Gonads.)  The  attempts  which 
have  generally  been  made  to  establish  normal  standards  in  relation 
to  age  have  led  to  more  or  less  confusion.  Pressure  increases  with 
age,  and  during  the  first  month  of  life  the  normal  range  lies  between 
60  and  68  mm.  Hg.  Some  recent  investigations  have  shown  that 
blood-pressure  increases  with  height  and  weight,  and  that  these 
criteria  are  more  definitely  fixed  than  the  mere  age  factor.*  Further, 
the  variations  which  have  been  attributed  to  the  influence  of  sex 
are  really  dependent  upon  the  effect  of  height  and  weight. 

Comparison  of  Bodily  Height  and  Systolic  Blood-pressure.' 

Systolic 
blood-pressure. 
Height.  Mm. 

3  feet  6  inches 99 

4  feet  to  4  feet  3  inches 109 

4  feet  3  inches  to  4  feet  6  inches 112 

4  feet  6  inches  to  4  feet  9  inches 118 

4  feet  9  inches  to  5  feet 120 

5  feet 125 

*  Melvin  and  Murray:  Blood-pressure  Estimation  in  Children,  British  Med.  Jour., 
April  17,  1915,  p.  2833. 

^  Congenital  Cardiac  Disease,  Osier  and  McCrae's  Modern  Med.,  1915,  iv,  411. 

'  Balard,  P. :  Le  Pouls  et  la  Tension  Art6rielle  de  I'Enfant  et  du  Nouveau-ne, 
Gaz.  des  H6p.,  1913,  Ixxxvi,  837. 

<  Wolfensohn-Kriss :  Ueber  Blutdruck  im  Kindesalter,  Arch.  f.  Kinderheilk.,  liii, 
Nos.  4-6. 

'Michael,  M.:  A  Study  of  Blood-pressure  in  Normal  Children,  Am.  Jour.  Dis. 
Child.,  1911,  i,  272. 


BLOOD-PRESSURE  AND  PHYSICAL  EFFICIENCY  379 

Comparison  of  Weight  and  Blood-pkessube. 

Blood-pressure. 
Mm. 


Weight. 

30  to 

40  lbs 

40  to 

50 

50  to 

60 

60  to 

70 

70  to 

80 

80  to 

90 

90  to  100 

95 
100 
107 
112 
116 
122 
126 


The  foregoing  tables  explain  the  statement  frequently  made 
that  "robust"  children  have  higher  pressures  than  delicate  ones, 
and  perhaps  also  that  breast-fed  infants  give  higher  readings  than 
those  artificially  nourished.  Popoff  ^  found  the  systolic  and  diastolic 
pressures  in  the  newborn  infant  to  average  75  and  34  mm.  Hg. 
respectively.  Prematurely  born  infants  had  lower  pressures  (see 
page  56).  Laitao  found  that  at  the  end  of  seven  months  the  systolic 
pressure  was  generally  100  mm.,  and  that  the  imhe-iyressure  which 
during  the  first  month  averaged  18  mm,,  at  the  end  of  the  first 
year  had  reached  28  mm.^  These  values  are  higher  than  those 
obtained  by  Kaupe,^  who  found  an  average  pulse-pressure  of  8  to 
10  mm.  Hg. 

In  infants  after  feeding  the  pressure  is  increased  8  to  10  mm., 
and  during  sleep  pressure  ranges  between  60  and  70  mm.  In 
children  an  hour's  exercise  may  elevate  the  pressure  5  to  10  mm., 
at  which  point  it  may  remain  for  half  an  hour  (Trumpp)  (see  also 
Acute  Infections,  page  204). 

Blood-pressure  and  Physical  Efficiency. — Studied  from  the 
stand-point  of  the  "Intercollegiate  Standard,"  which  consists  of  an 
addition  of  the  strength  of  the  back,  plus  that  of  the  legs,  plus  that 
of  the  right  and  left  forearms,  plus  the  lung  capacity  divided  by  20, 
plus  bodily  weight  divided  by  10  and  the  multiplication  of  the  last 
figure  by  number  of  times  the  subject  is  able  to  dip  his  body  by 
the  strength  of  his  arms  and  shoulders,  Barach  and  Marks  found 
that  there  is  no  constant  relation  between  physical  efficiency  (which 
also  means  circulatory  efficiency),  and  either  the  pulse-pressure, 
diastolic  pressure  ratio,  nor  between  the  pulse-pressure  percentage 
of  the  diastolic  pressure. 

>  Beitrag  z.  Frage  nach  d.  Blutdruck  b.  gesunden  Kindern,  Dissert.  St.  Peters- 
burg, 1913.  p.  200. 

''Laitao,  M.:  Pression  Art^rielle  chez  Tenfant,  Arch.  d.  Mai.  d.  Enfants,  1913, 
xvi,  102. 

'  Der  Blutdruck  im  Kindesalter,  Monatsschr.  f.  Kinderheilk.,  1910,  ix,  257. 


380     METABOLIC  DISEASES  AND  MISCELLANEO  US  CONDITIONS 

The  following  tables  compiled  by  Barach  and  Marks^  show  the 
actual  systolic  and  diastolic  pressures  encountered  among  742 
male  students: 

Age  Distribution  in  a  SeijiEs  of  552  Consecutive  Cases. 

Age,  Years.  Cases. 

15  to  17 27 

17  to  19  .      . 200 

19  to  21 202 

21  to  23 71- 

23  to  25 31 

25  to  27 12 

27  to  29 6 

29  to  31 1 

Over  31 '  2 

Total 552 


DlSTKinUTION    OF    MAXIMUM    PRESSURE    IN    656    CaSES. 

Mm.  Hg.  Cases. 

90  to  100 7 

100  to  110 23 

110  to  120 112 

120  to  130 204 

130  to  140 153 

140  to  150 95 

150  to  160 45 

160  to  170 14 

170  to  180  1 

180  to  190           3 

190  to  200  J 

Total 656 


Minimum  Pressure  Read  at  the  Last  Clear  Sound. 

Mm.  Hg.  Cases. 

40  to    50 1  1 

60  to    60 4  I 

60  to    70 12     070  0-7 

70  to    80 4j  f  273  cases  or  87  per 

80  to    90 94 

90  to  100 121 

100  to  110 27 

110  to  120 9 

120  to  130 3 


cent. 


Total 312 

'  Blood-pressures:   Their  Relation  to  Each  Other  and  to  Physical  Efficiency,  Arch. 
Int.  Med.,  1914,  xiii,  648. 


BLOOD-PRESSURE  AND  PHYSICAL  EFFICIENCY       381 


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382     METABOLIC  DISEASES  AND  MISCELLANEOUS  CONDITIONS 

The  foregoing  tables  are  taken  from  Judson  and  Nicholson/ 
who  include  their  own  figures  based  upon  a  study  of  2300  children. 
As  these  authors  point  out,  "The  widest  variations  occur  from  the 
tenth  to  the  fourteenth  year  when  there  is  a  marked  rise  in  the 
systolic  pressure.  From  the  fourth  to  the  fourteenth  year,  inclusive, 
the  variations  do  not  exceed  5  mm.  in  two-thirds  of  the  cases." 
Their  systolic  readings  were  higher  than  those  previously  obtained 
by  others.  There  is  a  gradual  rise  of  pressure  as  age  increases 
between  the  ages  studied,  amounting  in  all  to  14  mm.  Hg.  Up  to 
eight  years  of  age  a  9  cm.  cuff  gives  accurate  readings,  but  after 
eight  years  a  13  cm.  armlet  should  be  employed.  The  onset  of  the 
fourth  auscultatory  phase  (muffling)  must  be  used  as  the  diastolic 
criterion. 

Athletics. — The  physician  is  frequently  consulted  regarding  the 
advisability  of  allowing  certain  individuals  with  functional  or 
organic  heart  lesions  to  indulge  in  athletic  exercises.  The  tendency 
at  present  is  certainly  to  be  more  liberal  in  what  may  be  allowed 
than  was  formerly  the  case.  This  is  specially  true  of  children  and 
young  adults  with  heart  murmurs.  Before  assenting  to  or  advising 
such  procedures,  however,  we  must  realize  that  although  exercise 
is  as  necessary  for  the  heart  as  for  any  other  muscle,  yet  certain 
forms  of  exercise  throw  an  enormous  burden  upon  the  circulatory 
apparatus  (see  page  49). 

Any  exercise  which  increases  the  pulse-rate  will  also  in  a  normal 
individual  raise  blood-pressure.  This  results  not  only  from  the  more 
rapid  heart  rate  but  also  from  an  enlarged  systolic  output. 

After  exercise  blood-pressure  falls  below  normal.  This  applies 
to  all  the  pressures,  but  the  systolic  element  falls  more  rapidly  than 
the  diastolic,  and  thus  the  volume  of  the  pulse  decreases.  The  more 
strenuous  and  exhausting  the  exercise  the  longer  will  pressure  remain 
subnormal.  After  moderate  exercise  pressure  remains  low  for  about 
half  an  hour.  After  a  sudden  sprint  of  one  hundred  yards  it  may  re- 
quire three  times  as  long  before  the  normal  level  is  reached .  Lo wsley^ 
suggests  that  when  the  subnormal  phase  is  overcome  in  the  space  of 
an  hour,  the  exercise  may  be  considered  well  within  the  hygienic 
limits  for  the  individual,  but  that  a  depression  lasting  two  hours 
should  be  regarded  as  excessive. 

The  more  sudden  and  violent  the  exercise  (sprinting,  hammer 
throwing,  etc.),  the  greater  the  rise  of  blood-pressure  (200  mm.) 

*  Blood-pressure  in  Normal  Children,  Am.  Jour.  Dis.  Child.,  1914,  xii,  257. 
'  The  Effects  of  Various  Forms  of  Exercise  in  Systolic,  Diastolic  and  Pulse-pressures 
and  Pulse  Rate,  Am.  Jour.  Physiol.,  1910-11,  xxvii,  446. 


EFFECT  OF  MARATHON  RACES  383 

and  the  more  rapid  the  pulse.  Endurance  exercises  (long  distance 
running,  etc.),  produce  a  more  gradual  and  less  extreme  rise  of 
pressure,  but  a  pressure  which  remains  high  for  a  longer  time.  The 
sudden  changes  of  pressure  in  the  former  group  probably  do  no 
harm  to  young  normal  individuals  with  resilient  arteries,  but  they 
should  be  avoided  by  elderly  men  in  whom  permanent  cardiac 
dilatation  may  result.  The  prolonged  strain  of  endurance  exercises 
among  young  growing  children  should  certainly  not  be  encouraged 
(McKenzie). 

The  EfEect  of  Marathon  Races. — Before  the  Race. — Most  of  the 
men  had  trained  for  six  to  nine  months  preceding  the  race  of  twenty- 
four  miles.  The  majority  showed  evidences  of  cardiac  enlarge- 
ment and  had  a  slower  pulse  rate  than  normal.  The  cases  which 
showed  a  more  than  average  diurnal  pulse  variation  also  showed  a 
cardiac  hypertrophy  and  an  increased  blood-pressure.  The  highest 
blood-pressures  were  found  in  coincidence  with  the  largest  hearts. 
The  men  who  had  heart  murmurs  had  even  larger  hearts  and  higher 
pressures.  As  one  would  expect  the  men  who  were  overweight, 
whose  occupations  were  laborious,  and  whose  periods  of  preliminary 
training  were  short,  showed  higher  than  average  cardiac  enlarge- 
ment and  blood-pressures. 

After  the  Race. — The  average  fall  of  blood-pressure  was  20  mm. 
Cases  with  heart  murmurs  showed  an  even  greater  drop.  Some 
eases  showed  marked  cardiac  dilatation  (.r-ray),  and  in  these 
blood-pressure  was  lower  than  in  those  whose  heart  dilated  less. 
At  the  end  of  six  months  both  heart  and  blood-pressure  examina- 
tions yielded  normal  findings  in  most  of  the  cases  but  some  increased 
much  more  slowly  than  others.^ 

If  there  is  any  doubt  whatever  regarding  the  organic  character 
of  a  murmur  it  is  better  to  err  on  the  safe  side  and  advise  against 
prolonged  or  severe  forms  of  athletics. 

Much  has  been  written  of  late  concerning  the  evil  effects  of  over- 
athleticism,  and  regarding  this  subject  there  is  much  difference  of 
opinion. 

Severe  exercise  of  an  hour  has  been  shown  to  not  infrequently 
cause  the  appearance  of  albumin,  casts  and  blood  cells  in  the  urine 
of  healthy  subjects,  phenomena  which  are  doubtless  due  to  circula- 
tory changes  in  the  kidney  at  a  time  when  waste  products  in  large 
amount  must  be  eliminated.^ 

1  Savage,  W.  L. :  Physiological  and  Pathological  Effects  of  Severe  Exertion 
(The  Marathon  Race),  Am.  Phys.  Educ.  Rev.,  1910,  xv,  No.  9;  19;  1,  xvi,  Nos.  1-5. 

2  Barach,  J.  H.:  Against  Overathleticism,  Tr.  IV  Internat.  Congress  of  School 
Hygiene,  Buffalo,  August,  1913. 


384     METABOLIC  DISEASES  AND  MISCELLANEOUS  CONDITIONS 

Prolonged  and  severe  athletic  training  produces  demonstrable 
cardiac  hypertrophy  with  increased  blood-pressure.  These  phe- 
nomena may  be  transient  and  ephemeral,  but  they  are  not 
always  so. 

It  certainly  does  not  seem  -reasonable  to  believe  that  Marathon 
races  run  by  poorly  developed  and  untrained  individuals,  as  we 
see  them  in  our  city  streets,  can  be  beneficial.  Nor  does  it  seem 
logical  to  assume  that  four-mile  boat  races  at  the  end  of  which  even 
trained  athletes  go  into  a  state  of  syncope,  can  be  considered 
healthful  exercise.  It  is  believed  by  some  that  strenuous  athletics 
use  up  an  individual's  reserve  force — his  vital  reserve.  Whether 
this  be  so  or  not  cannot  be  proved,  but  certainly  the  picture  of  the 
husky  giant  who  succumbs  in  the  early  stages  of  typhoid  fever  or 
pneumonia  is  an  all  too  common  one. 

It  is  very  questionable  whether  in  the  ordinary  course  of  life, 
the  "athletic  heart"  is  an  asset.  Investigations  among  the  athletes 
at  the  University  of  Wisconsin  have  shown  cardiac  abnormalities 
among  a  considerable  proportion  of  the  athletes.^  This  has  been 
attributed  by  some  apologists  to  faulty  methods  of  training.  The 
report  of  the  Surgeon-General  of  the  United  States  Navy  attributes 
a  large  excess  of  deaths  attributable  to  cardiac  overstrain  among 
the  cadets  of  Annapolis,  to  overathleticism.  In  cardiac  cases  the 
physician  carefully  questions  the  patient  regarding  antecedent  infec- 
tions, but  rarely  in  regard  to  athletic  overindulgence  or  mishaps. 

It  seems  merely  conservative,  therefore,  to  insist  that  competitive 
athletics  should  be  conducted  only  under  competent  medical 
supervision,  and  that  growing  boys  should  not  be  allowed  to  indulge 
in  the  prolonged  and  exhausting  competitions  which  greatly  tax 
even  a  fully  developed  heart. 

Blood-pressure  observations  made  upon  men  carrying  the  regular 
soldier's  equipment  of  the  German  army  during  an  endurance 
march,  showed  in  those  between  the  ages  of  eighteen  and  twenty-five 
a  fall  of  12  mm.;  under  eighteen  years  it  was  19  mm.,  and  in  older 
men  averaged  38  mm.  Hg.^  The  stress  and  strain  of  the  present 
war  according  to  Moutier  is  accountable  for  many  cases  of  hypo- 
tension. Even  hypertensive  individuals  are  said  sometimes  to 
return  on  furlough  with  a  normal  pressure.  He  also  reports  variable 
tension  in  the  two  arms  when  one  has  been  injured,  sometimes 
higher  but  generally  lower  in  the  traumatized  member. 

1  Schumacher,  L.,  and  Middleton,  W.  S.:  The  Cardiac  Effects  of  Immoderate 
College  Athletics,  Jour.  Am.  Med.  Assn.,  1914,  Ixii,  1136. 

'  Thiele :  Aerztliche  Beobachtungen  an  Teilnehmer  eines  Armee-Gepaecksnarsches, 
Deutsch.  med.  Wehnschr.,  1915,  xli,  1425. 


BLOOD-PRESSURE  IN  G ASTRO-ENTERITIS  385 

The  Effect  of  Athletic  Training. — ^Training  renders  an  individual 
more  efficient  (1)  by  increasing  cardiac  and  vasomotor  responses 
to  meet  sudden  or  prolonged  demands  for  physiological  activity; 
(2)  by  educating  the  brain  centres  so  that  muscular  actions  become 
semi-automatic  and  hence  less  volition  is  required  in  their  perform- 
ance; (3)  by  accustoming  the  medullary  centres  to  an  increased 
quantity  of  carbon  dioxide;  and  (4)  by  increasing  the  rate  of 
excretion  of  waste  products  of  metabolic  activity. 

Middleton^  has  found  that  training  during  a  football  season 
produces  fairly  uniform  results  which  may  be  expressed  as  follows : 

1.  A  proportionate  decrease  in  both  systolic  and  diastolic  pressure 
during  the  training  period. 

2.  After  the  rest  following  the  training  season  a  rise  of  both 
pressures  occurs  which  exceeds  the  anteseason  records. 

3.  The  blood-pressure  reaction  to  a  test  of  fifty  stationary  run- 
ning steps  is  practically  unaltered  by  the  training. 

The  decrease  in  the  blood-pressure  mentioned  may  be  due  to 
peripheral  vascular  relaxation  or  to  cardiac  dilatation,  or  to  a  com- 
bination of  both  factors. 

Blood-pressure  in  Gastro-enteritis. — ^The  suggestion  has  been 
made  that  the  collapse  which  occurs  in  the  course  of  epidemic 
diarrheas  is  in  part  due  to  a  fall  of  blood-pressure  resulting  from 
loss  of  fluid  in  the  tissues  thus  producing  anuria,  and  that  saline 
infusion  should  be  used  in  combating  this  symptom^  (see  Cholera, 
page  207). 

Vomiting  causes  a  fall  of  blood-pressure  which  is  in  part  due  to 
the  cardiac  inhibition  which  occurs  when  the  vomiting  centre  is 
stimulated^  not  only  a  fall,  however,  but  very  sudden  and  extensive 
pressure  variations  are  also  met  with.^ 

'  The  Influence  of  Athletic  Training  on  Blood-pressure,  Am.  Jour.  Med.  Sc,  1915, 
cl,  426. 

'  British  Jour.  Child.  Dis.,  1912,  ix,  343. 

»  Miller:    Am.  Jour.  Physiol.,  May,  1915. 

*  Brooks  and  Luckhardt:  Blood-pressure  during  Vomiting,  Am.  Jour.  Physiol., 
1915,  xxxvi,  104. 


25 


CHAPTER    XVI. 
DISEASES  OF  THE  NERVOUS  SYSTEM. 

Neurasthenia. — When  we  consider  what  a  large  number  of  dif- 
ferent organic  and  functional  abnormalities  go  to  make  up  the 
clinical  picture  of  this  condition  it  is  not  surprising  to  note  that 
blood-pressure  findings  are  inconstant.  As  has  been  described 
elsewhere,  many  of  these  cases  belong  in  the  category  of  "con- 
stitutional low  arterial  pressure"  (q.  v.),  but  some  cases  have  been 
reported  as  associated  with  hypertension.  Symptomatic  improve- 
ment is  generally  attended  by  the  reestablishment  of  a  more  normal 
pressure,  whether  this  means  a  rise  or  fall.^  "Neurasthenia" 
associated  with  high  blood-pressure  generally  calls  for  a  revision  of 
diagnosis,  which  will  not  infrequently  be  changed  to  nephritis  or 
cardiovascular  hypertensive  disease. 

"In  true  neurasthenia,  in  real  exhaustion  of  the  nervous  centres 
from  whatever  cause  arising,  the  blood-pressure  is  low,  lower  than 
in  any  other  chronic  malady,  except  the  terminal  phases  of  cancer 
tubercle  and  other  wasting  disease"  (Leonard  Williams).  The 
effects  of  prolonged  mental  and  physical  strain  and  exhaustion, 
as  exemplified  by  soldiers  returning  from  the  battle  front  in  France, 
produces  arterial  hypotension.  Moutier  reports  that  a  well-marked 
fall  in  pressure  occurs  both  in  soldiers  starting  out  with  normal 
pressures  and  in  those  who  do  so  with  hypertension. 

Neuroses,  etc. — In  the  neuroses  unequal  radial  pressure  on  the 
two  sides  is  often  found  as  well  as  a  general  lability  of  pressure. 
These  signs  may  be  of  use  in  diagnosticating  between  neurosis  and 
simulation.^  Pain  produces  a  rise  of  blood-pressure  and  an  increased 
pulse  rate.  Simulated  pain  does  not.  This  fact  has  been  turned 
to  practical  application  in  the  detection  of  malingering  in  relation 
to  industrial  insurance.  In  persons  with  normal  sensibility  the 
blood-pressure  under  the  application  of  faradic  stimulation  to  the 
upper  thigh  rises  from  8  to  15  mm.    In  organic  affections  of  the 

>  Macnamara:    Lancet,  July  18,  1908. 

'  Sand:  Les  Anomalies  de  la  Tension,  Sanguine,  etc.,  Arch,  intern,  de  MM. 
Legale,  1910,  p.  349. 


MENTAL  DISEASE  387 

spinal  cord,  multiple  sclerosis,  hysteria,  etc.,  it  remains  unaffected 
when  stimulation  is  applied  to  analgesic  regions.^ 

If  the  systolic  pressure  is  taken  in  one  arm  and  simultaneously 
the  diastolic  pressure  in  the  other  (for  celerity  of  procedure,  and 
the  subject  is  emotionally  disturbed  by  conversation,  gesture,  or 
the  application  of  ice  to  the  abdomen,  (1)  marked  variations  of 
the  maximum  pressure  are  said  to  indicate  abnormal  stimulability; 
(2)  if  the  diastolic  pressure  meanwhile  remains  unaltered  the 
vascular  system  is  normal;  (3)  if  the  diastolic  pressure  shows 
sudden  variations  of  over  15  per  cent,  of  the  systolic  pressure  we 
are  dealing  with  arteriocapillary  sclerosis.^  Landerer  found  abnor- 
mal arteriocapillary  pressure  relations  in  neuroses. 

Peripheral  Neuritis. — ^In  the  early  stages  of  brachial  neuritis, 
Stewart  found  the  blood  flow  greater  than  in  the  unaffected  hand, 
a  finding  which  he  interpreted  as  indicating  a  partial  paralysis  of  the 
vasoconstrictor  fibers  in  the  nerves  involved. 

In  neuritis  affecting  chiefly  the  muscular  nerves,  disturbances 
of  the  blood  flow  were  less  conspicuous  than  when  the  cutaneous 
nerves  were  involved.  This  is  presumably  due  to  the  fact  that  a 
large  amount  of  the  total  blood  supply  of  the  extremities  traverses 
the  skin  of  the  parts. 

Cases  of  long-standing  unilateral  neuritis  were  found  by  Stewart 
to  show  a  diminished  blood  flow  on  the  side  affected,  owing  either 
to  diminution  of  the  arterial  lumen  following  injury  of  the  vasomotor 
nerves  or  perhaps  to  an  adaptive  correllation  between  diminished 
function  and  blood  supply. 

Mental  Disease. — The  reports  on  blood-pressure  in  abnormal 
psychic  states  are  so  variable  and  contradictory,  and  the  range  of 
abnormality  so  slight,  that  one  cannot  but  feel  that  in  the  majority 
of  cases  at  least  no  definite  relationship  exists.  Nor  is  this  surprising 
when  we  consider  how  greatly  blood-pressure  is  normally  affected 
by  emotional  disturbances. 

In  simple,  acute,  passive,  and  demonstrative  melancholia  high 
pressures  have  been  reported,  whereas  chronic  melancholia  is 
associated  with  hypotension.  Hawley  states  that  cases  of  mania 
show  definite  and  typical  blood-pressure  changes — a  large  pulse 
amplitude  with  sudden  pulsatory  oscillations  and  an  increased 
pressure.  These  phenomena  disappear  when  the  mental  state  again 
becomes  normal.    In  pure  senile  mania  and  melancholia  the  readings 

*  Curschmann:    Deutsch.  med.  Wchnschr.,  October  15,  1907. 

'  Schrumpf  and  Zabel:  Die  diagnostische  Bedeutung  der  psychogenen  Labilitat 
des  Bhitdruckes,  Miinchen.  raed.  Wchnschr.,  1911,  Iviii,  1952. 


388  DISEASES  OF  THE  NERVOUS  SYSTEM 

correspond  to  those  registered  in  the  same  states  in  earlier  life. 
Senile  dementia,  characterized  by  restless  fidgeting,  etc.,  shows 
increased  pressure.^  In  depressed  and  stuporous  mental  states 
low  pressures  are  found.^ 

The  vasomotor  unrest  of  the  insane  has  been  corroborated  by 
Enebuske^  who  makes  the  following  observations  after  20,000 
blood-pressure  estimations.  Characteristic  of  the  manodepressive 
group  is  vasomotor  unrest  at  a  hypertensive  level,  continuous  within 
certain  periods  of  time.  In  other  words,  there  are  frequent  pressure 
alterations  with  an  average  high  level  (150  mm.).  The  variability 
ceases  after  a  time  and  when  blood-pressure  has  become  stabilized 
the  disease  has  either  run  its  course  or  become  altered. 

In  the  precox  group  continuous  vasomotor  unrest  also  occurs, 
but  at  a  lower  level.  Pressure  variations  are  more  marked  than  in 
the  manodepressive  class,  and  the  vasomotor  unrest  is  continuous 
without  a  time  limit  through  periods  of  remission  with  vasomotor 
tranquility  (except  for  periodical  precox).  In  all  of  the  preceding 
forms,  pressure  levels  vary  during  the  acute  and  subacute  stages. 
During  the  periods  of  vasomotor  tranquility  the  patients  are  more 
responsive  and  receptive  to  treatment. 

Dementia  Precox. — According  to  Perazzolo^  74  per  cent,  of  these 
cases  have  a  low  blood-pressure.  Turner  found  no  definite  relation 
between  blood-pressure  and  either  exalted  or  depressed  mental 
states.  The  height  of  the  pressure  seemed  mainly  dependent  upon 
the  age  of  the  patient  and  upon  the  presence  of  renal  or  cardio- 
vascular complications.^ 

Epilepsy. — Epileptics  not  infrequently  have  a  slow  pulse  rate, 
a  low  blood-pressure,  and  evidences  of  peripheral  stasis.  Russell,® 
in  his  Goulstonian  lecture,  enumerated  many  interesting  and 
suggestive  points  in  an  analogy  between  epileptic  seizures  and 
vascular  spasm.  We  cannot,  however,  assume  that  such  conditions 
affect  the  cerebral  vessels  in  the  same  manner  as  or  simultaneously 
with  the  peripheral  arteries.  Furthermore,  there  is  still  some 
difference  of  opinion  as  to  whether  the  cerebral  vessels  possess 
vasomotor  nerves.     But  the  clinical  picture  of  epilepsy  presents 

1  Alexander:    Lancet,  July  5,  1902. 

*  Hawley :  Blood-pressure  in  States  of  Excitement  and  Depression,  Arch.  Int.  Med., 
1913,  xii,  526. 

'  Boston  Med.  and  Surg.  Jour.,  March  15,  1917,  No.  11. 

*  Revista  sperimentale  di  Freniatria,  April  30,  1909. 

'  Turner:  Observations  on  the  Blood-pressure  and  Vascular  Disease  in  the  Female 
Insane,  Jour.  Ment.  Sc,  1909,  xlv,  419 

« Some  Disorders  of  the  Cerebral  Circulation  and  Their  Clinical  Manifestations, 
Lancet,  April  3,  1909,  pp.  963,  1031,  1093. 


BRAIN  TUMORS,  HEMORRHAGES,  AND  MENINGITIS     389 

many  features  which  fit  well  into  a  hypothesis  of  vasomotor  crises 
(aura,  pallor,  syncope,  convulsions,  etc.). 

Blood-pressure  has  been  found  to  increase  several  hours  before 
the  attack  begins.  During  the  seizure  it  is  said  to  rise  still  further 
(20  per  cent.)  and  to  fall  after  the  attack;  but  often  to  remain 
somewhat  elevated  between  paroxysms.^  It  has  been  shown  that 
in  many  cases  rhythmic  blood-pressure  variations  occur  which 
are  not  due  to  respiratory  movements  (Traube-Hering  waves). 
Preceding  the  seizure  (twenty-six  to  sixty  seconds)  there  is  a  rise 
of  pressure  (followed  in  some  cases  by  a  sudden  fall),  then  apnea, 
and  finally  the  convulsion.^  The  pulse  is  variable.  "A  study  of 
the  changes  in  the  respiratory  and  circulatory  systems  in  some 
of  the  cases  of  epilepsy  suggests  that  the  site  of  the  discharge  is 
in  the  medulla  and  pons  (the  'lowest  level  of  fits'  of  Hughlings 
Jackson).  Likewise  it  points  to  the  medulla  as  participating  in 
the  discharge  in  all  cases  of  epilepsy  whether  this  discharge  originates 
them  or  not.'"^ 

Brain  Tumors,  Hemorrhages,  Meningitis,  etc. — The  increased 
intracranial  tension  which  occurs  in  cases  of  apoplexy  and  brain 
tumor  may  be  closely  simulated  experimentally.  The  symptoms 
of  the  two  conditions  as  well  as  their  mechanism  is  essentially 
similar.  Sudden  increase  of  intracranial  tension  produces  an 
acute  anemia  of  the  brain,  which,  being  enclosed  within  osseous 
confines,  is  relatively  incompressible.  The  only  possible  relief 
from  such  compression  can  come  through  absorption  of  the  cerebro- 
spinal fluid.  If  the  rise  in  arterial  tension  is  prevented  death  occurs 
from  medullary  anemia. 

With  increasing  compression  the  following  symptoms  generally 
occur  in  the  order  mentioned:  (1)  unconsciousness;  (2)  respiratory 
abnormalities;  (3)  increased  arterial  tension  with  bradycardia;  (4) 
hypotension,  tachycardia,  death.  Associated  with  these  symptoms 
rhythmic  fluctuations  of  blood-pressure  (Traube-Hering  waves)  and 
Cheyne-Stokes  respiration  are  apt  to  occur  (see  pages  43  and  300). 

The  attendant  rise  of  systemic  blood-pressure  is  therefore  com- 
pensatory: an  effort  to  prevent  medullary  anemia,  which  if  pre- 
vented causes  death.    The  symptoms  which  arise  are  for  the  most 

1  Lallemand  and  Rodiet:  Des  Modifications  de  la  tension  art6rielle  chez  les  epi- 
leptiques  L'Encephale,  iv,  No.  11. 

*  Gibson,  Good,  and  Penny:  The  Pulse  Immediately  Preceding  the  Epileptic 
Attack,  Quart.  Jour.  Med.,  1910,  iv,  1.  The  authors  could  find  no  alteration  of 
the  pulse  amplitude  up  to  the  point  of  the  seizure. 

'  Pollock  and  Treadway:  A  Study  of  the  Respiration  and  Circulation  in  Epilepsy, 
Arch.  Int.  Med.,  1913,  xi,  445. 


390  DISEASES  OF  THE  NERVOUS  SYSTEM 

part  due  not  directly  to  pressure  but  to  cerebral  anemia.  When 
intracranial  pressure  becomes  sufficiently  great  certain  symptoms 
and  signs  become  apparent  (headache,  vertigo,  vomiting,  choked 
disk,  etc.)-  If  pressure  is  increased  still  further,  bulbar  symptoms 
develop:  bradycardia,  hypertelision.  Finally,  if  anemia  threatens 
the  vital  centres  life  can  only  be  maintained  by  a  marked  rise  of 
general  blood-pressure,  and  this  at  least  intermittently  usually 
occurs.  Some  of  the  highest  blood-pressure  readings  on  record 
(300  mm.+)  have  been  encountered  under  these  conditions. 
Eventually,  unless  the  pressure  is  relieved,  death  occurs  as  a  result 
of  central  and  systemic  exhaustion,  preceded  by  a  fall  of  tension 
and  an  increased  pulse  rate  (see  page  45). 

Any  increase  of  the  cerebrospinal  pressure,  whether  due  to  tumor, 
softening,  hemorrhagic  meningitis,  cerebral  or  cerebrospinal  menin- 
gitis (serous  or  purulent)  tends  to  cause  a  rise  of  systemic  blood- 
pressure.  Especially  is  this  the  case  if  the  pressure  is  exerted  in  the 
posterior  cerebral  fossa,  causing  a  stimulation  of  the  vasoconstrictor 
centre,  and  if  the  rise  of  intracranial  pressure  be  rapid.  Brain 
tumors  are  usually  slow  in  growth  and  arterial  hypertension,  brady- 
cardia and  respiratory  disturbances  are  not  marked  unless  a  sud- 
den increase  of  intracranial  tension  occurs — hemorrhage,  edema  or 
ventricular  effusion  (Gushing). 

If  the  cerebrospinal  pressure  is  relieved  by  lumbar  puncture  or 
trephining,  blood-pressure  falls,  the  bradycardia  is  replaced  by 
a  normal  pulse  rate  and  respiratory  abnormalities  disappear. 
There  is  often  a  distinct  parallelism  between  the  two  pressures.^ 

From  what  has  been  stated  it  is  evident  that  phlebotomy  is 
generally  contra-indicated  in  cases  of  cerebral  hemorrhage.  On  the 
other  hand,  a  progressively  rising  arterial  pressure  is  often  the  most 
useful  indication  of  an  increase  of  hemorrhage  and  of  consequent 
cerebral  compression,  and  may  therefore  be  used  as  a  criterion  as 
to  whether  an  operation  for  decompression  is  or  is  not  warranted. 

Apoplexy. — Marked  hypertension  is  unquestionably  a  predis- 
posing and  often  the  direct  cause  of  apoplexy,  but  less  than  15  per 
cent,  of  the  cases  having  a  pressure  of  or  above  200  mm.  die  from  this 
cause.  Furthermore,  apoplexy  may  occur  in  patients  whose  pressure 
has  never  been  recorded  as  being  over  170  mm.  Immediately  after 
an  apoplexy,  bradycardia  with  very  high  blood-pressure  is  some- 
times seen.  These  symptoms  result  from  increased  intracranial 
pressure.    The  usual  range  of  pressure  "after  a  stroke"  is  between 

•  Parisot,  J.:  Hypertension  cephalo-rachnidienne  et  pression  arterielle,  Compt. 
rend.  Soc.  de  biol.,  1909,  Ixvi,  939. 


HEMIPLEGIA  391 

150  and  200  mm.,  but  normal  pressures  may  be  found,  or  higher 
pressures  (300  mm.+)  than  are  encountered  in  ahnost  any  other 
clinical  condition.  Hemorrhage  into  the  anterior  fossa  is  less  apt 
to  raise  blood-pressure  than  when  it  occurs  in  the  posterior  fossa, 
especially  in  proximity  to  the  fourth  ventricle.  Briggs  has  reported 
a  pressure  of  400  mm.  Hg.  The  value  of  pressure  readings 
depends  mainly  upon  a  knowledge  of  the  pressure  which  existed 
preceding  the  attack.  It  is  more  important  to  know  the 
general  trend  of  the  pressure — whether  upward  or  downward 
than  actual  figures.  Thus  a  steadily  rising  pressure  indicates 
cerebral  compression  and  may  call  for  decompression,  whereas  a 
steady  fall  points  to  vasomotor  failure,  which  often  leads  to  death. 
Blood-pressure  readings  may  be  of  value  in  diagnosticating  between 
apoplexy  and  embolism.  High  pressure  is  evidence  in  favor  of  the 
former,  and  low  pressure,  of  the  latter.  It  appears,  however,  that 
apoplexy,  even  when  associated  with  hypertension  and  chronic 
nephritis,  is  more  commonly  due  to  thrombosis  with  cerebral 
softening  than  to  actual  vascular  rupture.  Certainly  this  has  been 
the  case  at  the  Philadelphia  General  Hospital.  This  statement  is 
borne  out  by  Cadwalader's^  investigations,  from  which  it  appears 
that  many  non-fatal  hemiplegias  are  due  to  vascular  obstruction 
and  softening  rather  than  to  hemorrhage,  which  is  much  more  apt 
to  cause  death. 

The  importance  of  pressure  exacerbations  as  induced  by  exercise 
in  precipitating  apoplexy  has  perhaps  been  overestimated,  a  con- 
siderable number  of  "strokes"  occurring  while  the  patients  are  at 
rest  if  not  actually  asleep,  although,  theoretically,  increased  pressure 
would  tend  to  favor  apoplexy  or  embolism,  and  decreased  pressure 
thrombosis.  The  statement  has  been  made  that  in  cases  of  hemi- 
plegia, due  to  thrombosis,  the  pulse  is  rapid,  intermittent  and  of 
low  tension,  whereas  hemorrhage  produces  hypertension  and  brady- 
cardia. This  appears  to  be  true  in  typical  cases.  Often  even 
rapidly  fatal  cases  of  hemorrhage  fail  to  show  either  of  the  last- 
named  symptoms  (Collins). 

Hemiplegia. — Pressure  differences  in  corresponding  extremities 
are  not  infrequently  seen  in  cases  of  hemiplegia.  Dana  states  that 
marked  differences  on  the  two  sides  of  the  body  suggest  involve- 
ment of  the  optic  thalamus.^  Stewart  found  an  abolition  of  vascular 
reflexes  in  an  old  case  of  hemiplegia  on  the  affected  side  (see  page 

'  Comparison  of  the  Onset  and  Character  of  Apoplexy  Caused  by  Cerebral  Hemor- 
rhage and  by  Vascular  Occlusion,  Jour.  Am.  Med.  Assn.,  May  2,  1914,  p.  1385. 
2  Dana:    Jour.  Am.  Med.  Assn.,  December  19,  1909. 


392  DISEASES  OF  THE  NERVOUS  SYSTEM 

246).  "In  hemiplegia  there  is,  in  general,  a  marked  deficiency  in 
the  blood  flow  in  the  paralyzed  members.  Considerable  differences, 
however,  exist  in  different  cases  in  this  regard,  and  also  in  the  extent 
to  which  the  vasomotor  reflexes  from  the  normal  to  the  paralyzed 
part  are  affected.  Whether  these  differences  depend  at  all  on  the 
position  of  the  lesion  or  are  associated  with  the  duration  and  com- 
pleteness of  the  paralysis  has  not  been  determined.  There  is  some 
evidence  that  reflex  vasoconstriction  is  more  easily  produced  in  the 
paralyzed  parts  than  reflex  vasodilatation."^ 

It  has  been  shown  experimentally  that  in  dogs  and  cats  there 
is  a  limitable  region  of  the  cortex,  irritation  of  which  causes  a 
blood-pressure  increase  that  is  not  coextensive  with  the  motor 
zone,  but  is  in  cats  situated  more  anteriorly.  Irritation  of  this 
zone  is  sure  to  cause  splanchnic  constriction.  It  has  been  sug- 
gested, but  as  yet  not  demonstrated,  that  the  pressor  effects  of 
certain  cortical  regions  are  limited  in  their  action  to  certain  regions 
of  the  body.  The  occurrence  of  unilateral  differences  in  temperature 
and  edema  in  hemiplegia,  when  the  secondary  effects  of  muscular 
paralysis  can  be  excluded,  indicate  that  similar  cortical  pressor 
centres  exist  in  man.^ 

Locomotor  Ataxia. — ^The  crises  of  locomotor  ataxia  have  long 
been  recognized  as  clinical  manifestations  of  the  disease.  The 
etiological  part  taken  by  the  sympathetic  nerve  was  explained 
by  Duchenne.  Putnam  suggested  that  lesions  of  the  sympathetic 
nerve  might,  owing  to  their  influence  on  the  vasomotor  system, 
account  for  certain  secretory  abnormalities.  The  importance  of 
vascular  spasm  in  the  genesis  of  the  crisis  has  been  chiefly  cham- 
pioned by  Pal,  who  reported  a  number  of  cases  in  which  the  crises 
were  associated  with  hypertension  (in  one  case  240  mm.  Hg.)  and 
who  regards  the  abdominal  cramps  as  resulting  from  a  spasm  of 
the  splanchnic  arterioles,  and  a  stretching  of  the  nerve  plexuses  of 
the  arterial  wall.  The  attacks  are  sometimes  relieved  by  nitrite 
of  amyl.  The  rise  of  pressure  occurs  somewhat  before  the  onset 
of  pain,  which  begins  when  a  certain  variable  high  point  is  reached. 
The  arteries  become  tense  and  the  pulse  rate  increased.  The 
pressure  increase  generally  amounts  to  more  than  50  per  cent. 

Heitz  and  Norero^  believe  that  the  rise  of  pressure  is  the  result 
of  pain  which  they  explain  is  due  to  a  paroxysmal  irritation  of 

*  Stewart,  G.  N.:  Blood  Flow  in  the  Hands  and  Feet  in  Certain  Diseases  of  the 
Nervous  System,  Arch.  Int.  Med.,  1915.  xvi,  270. 

*  Lewandowsky,  W.,  and  Weber,  E.:  Blutdruck  u.  Hirnrinde,  Med.  Klinik, 
1906,  ii,  385. 

»  De  la  pression  artdrielle  chez  les  taWtiques,  Arch.  d.  mal.  du  cceur,  1908,  i,  505. 


SYRINGOMYELIA  393 

the  posterior  roots,  and  which  is  accompanied  by  local  reflex 
phenomena  in  the  corresponding  segments;  either  (1)  motor 
(vomiting,  constipation)  or  (2)  vasoconstrictor  (hypertension).  A 
rise  of  pressure  is  often  absent  in  old  cases  owing  to  degeneration 
of  the  posterior  roots,  especially  if  chronic  hypertension  is  associated. 
In  opposition  to  Pal  they  failed  to  find  arterial  hypertension  in  cases 
of  peripheral  crises,  although  in  most  of  their  cases  the  disease  was 
advanced.  Stewart  found  the  rate  of  blood  flow  in  both  hands  and 
feet  diminished  in  tabes;  together  with  feeble  vasomotor  reflexes. 

It  has  been  suggested  that  pressure  readings  might  be  of  diag- 
nostic value  in  differentiating  between  tabetic  crises  and  biliary 
or  renal  colic  since  much  higher  readings  occur  in  the  former.^ 

Paresis. — The  early  observations  of  blood-pressure  in  paresis 
made  by  Pilcz  and  Alexander  showed  hypotension.  Craig  found 
the  tension  high  during  mental  depression  and  low  during  exaltation. 
The  more  recent  studies  of  Walton^  indicate  that  the  average 
pressure  in  paresis  is  high,  due  doubtless  to  arteriosclerotic  accom- 
paniments. When  cardiac  and  renal  diseases  are  excluded  the 
pressure  is  slightly  lower  than  normal.  Such  hypotension  is, 
however,  neither  sufficiently  great  nor  constant  to  be  of  diagnostic 
or  prognostic  value.  The  excited  states  are  associated  with  variable 
pressures,  but  depression  is  more  often  accompanied  by  high  than  by 
low  pressures.  Toward  the  termination  of  the  disease  very  marked 
hypotension  may  occur. 

Sjrringomyelia. — ^In  a  case  of  syringomyelia  thermic  stimulation 
of  the  affected  arm  produced  no  reaction  in  its  fellow,  whereas 
similar  stimulation  of  the  unaffected  side  arm  produced  a  normal 
reaction  on  the  diseased  opposite  side.  These  findings  have  been 
construed  as  showing  that  sensible  stimuli  occur  in  the  "anti- 
dromal  direction"  after  the  manner  of  an  axon  reflex  and  produce 
a  vasodilatation.^ 

*  Jump,  H.  D. :  Value  of  Blood-pressure  Estimations  in  Internal  Medicine,  Internal. 
Clinics,  Series  21,  i,  49. 

*  The  Blood-pressure  in  Paresis,  Jour.  Am.  Med.  Assn.,  1906,  xlviii,  1341. 

'Hess,  L.,  and  v.  Bergmann,  E.:  Ueber  Gefaessreflexe,  Wien.  klin.  Wchnschr., 
1913,  xxvi,  1297. 


CHAPTER  XVII. 
BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS. 

The  Effects  of  Hemorrhage. — When  an  artery  of  large  size  is 
torn  or  cut  and  the  resultant  hemorrhage  is  considerable,  the 
diastolic  pressure  falls,  as  does  also  the  systolic  pressure,  although 
to  a  lesser  degree.  The  pulse-pressure  therefore  increases  and  the 
left  ventricle  continues  its  normal  output.  Peripheral  venous 
flow  is,  however,  promptly  reduced  and  soon  the  fall  in  venous 
pressure  fails  to  supply  an  "efl^ective"  right  auricular  pressure. 
As  a  result  of  inadequate  filling  of  the  right  heart,  pressure  falls 
in  the  pulmonary  artery  and  in  the  left  auricle,  and  systolic  left 
ventricular  output  promptly  falls.  The  medullary  centres  are 
stimulated  by  the  decreased  blood  flow,  the  pulse  rate  rises  from 
depression  of  the  cardio-inhibitory  centre  and  vasoconstriction 
results  from  central  stimulation.  In  addition  to  this  mechanical 
factor  chemical  changes  also  produce  their  effects.  The  loss  of 
erythrocytes  from  the  blood  stream  with  its  consequent  reduction 
in  the  oxygen-carrying  power  of  the  blood,  together  with  a  slug- 
gish circulation  in  the  peripheral  capillaries,  leads  to  a  decrease  in 
the  volume  per  cent,  of  oxygen  in  first  the  venous,  and  later,  the 
arterial  blood,  while  the  carbon-dioxide  content  of  each  remains 
unchanged.  This  reduction  in  the  hematogenous  oxygen  content 
causes  hyperpnea,  which  causes  for  the  time  being  a  better  average 
auricular  pressure.  In  brief,  "the  fall  of  arterial  pressures  is 
counteracted  by  the  augmented  breathing,  an  accelerated  heart, 
an  accommodative  contraction  of  the  larger  vessels  and  by  per- 
ipheral constriction  leading  to  an  increased  resistance  and  dimin- 
ished flow  in  spite  of  the  reduction  of  viscosity."^ 

When  hemorrhage  ceases  the  loss  of  the  blood  bulk  is  made  up 
by  the  absorption  of  lymph  from  the  tissues.  The  rise  of  blood- 
pressure  which  results  may  be  abetted  by  intravenous  saline  or 
salo-alkaline  infusion.  There  appears  to  be  no  experimental  evidence 
supporting  the  view  generally  held  that  active  secondary,  post- 
hemorrhagic vasoconstriction  plays  much  of  a  part  in  this  post- 
hemorrhagic rise  of  the  mean  pressure.^ 

The  consecutive  changes  occurring  during  hemorrhage  are 
represented  in  the  following  schemas  taken  from  Wiggers's  article. 

1  Wiggers,  C.  J.:  Modern  Aspects  of  the  Circulation  in  Health  and  Disease, 
Philadelphia,  1915,  p.  339. 

2  Wiggers,  C.  J. :  Pathological  Physiology  of  the  Circulation  during  Hemorrhage, 
Arch.  Int.  Med.,  1914,  xiv,  33. 


THE  EFFECTS  OF  HEMORRHAGE 


395 


SEQUENCE  OF  EVENTS  DURING  HEMORRHAGE. 
Reduction  in  Total  Volume  of  Blood. 


Reduction    in    red    cells    and 
percentage     of     hemoglobin 


Venous  blood-COs  unchanged 

decreased 

Arterial  blood-C02  increased 

O2  decreased 


Reduction  in  total  arterial  resistance 

i 
Decreased  diastolic  pressure 

i 
Increased  systolic  discharge  of  heart 

i 
Lower  systolic,  increased  pulse-pressure 

Decreased  flow  in  peripheral  veins 

i 
Decreased  right  auricular  pressure 

Decreased  output  of  right  ventricle 

i 
Decreased     pulmonary     arterial     pressure 
and  left  auricular  pressure 

i 
Decreased  output  of  left  ventricle 

i 
Smaller  pulse-pressure 

Further  fall  in  systolic  and  diastolic  press- 
ures I 

Decreased  flow  through  medulla 
^  I  \ 

/ V         i  N 

Stimulate  Stimulates  Depresses 

respiratory  centre  vasomotor  card.-inhib. 

(deeper  respirations)  centre  centre 

\  \  i  ^ 

Reductions  of  red  cells  by  \^    Tend  to  counteract  fall  of  pressure 

dilution  of  blood  \ 

i  \  / 

Decreased  viscosity  Tend  to  increase  flow  through  small  vessels 

SEQUENCE  OF  EVENTS  DURING  TERMINAL  STAGES. 

Loss  OF  Blood  Volume  Exceeds  Resorption  of  Lymph. 

Red  corpuscles  reduced  to  minimum 


Stream  slowed  in  tissues 

1 

Osmosis  toward  blood  stream 

.1 

Increase  in  volume 


/ 
/ 
Oxygen  percentage   in   arterial  \ 
blood  decreases 


Progressive  increase  in  COj<- 


\ 
\ 

Systolic  discharge  diminishes  due  to  lack 
of  diastolic  filling 

.        i 
Pulse-pressure  progressively  diminished 

\  i 

-^Respiratory  centre  depressed 


i 
Heart  depressed  by  anemia 

i 
Beats  slower.     Feebler 

\ 
Respiratory  periodic  gasps 

i. 
Asphyxial  conditions 

i 
Heart  slow,  large  amplitude  of  contraction 

\ 
Ventricular  fibrillation,  cessation 


396      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

Blood-pressure  readings  should  be  made  in  all  cases  in  which 
anesthetics  or  surgical  procedures  are  employed  before,  if  possible 
during,  and  after  the  operation.  Arterial  hypertension  will  often 
indicate  the  presence  of  renal  disease  when  the  routine  urine  exami- 
nation fails  to  reveal  it.  A  fall  of  pressure  during  the  course  of  the 
operation  is  one  of  the  surest  methods  of  detecting  the  beginning 
of  shock,  whether  this  occurs  during  or  after  the  conclusion  of  the 
operation.  A  fall  of  pressure  to  below  100  mm.  Hg.,  together  with 
a  rising  pulse  rate,  is  an  indication  for  immediate  treatment.  Shock 
is  at  hand  when  the  pulse-pressure  falls  to  10  to  15  mm.,  or  when  the 
diastolic  pressure  falls  to  or  below  70  mm.  Hg.  (McKesson).  When 
possible  the  patient's  normal  pressure  should  be  obtained  the  day 
before  the  operation,  or  at  least  not  immediately  preceding  it, 
because  fear  and  excitement  both  tend  to  increase  the  systolic 
pressure  and  the  pulse  rate.  A  steady  pressure  is  the  best  indication 
of  a  satisfactory  condition  on  the  part  of  the  patient.  Fluctuations 
of  tension  point  to  exhaustion.  Patients  with  marked  hypertension 
(180  to  210  mm.  Hg.)  require  special  care.  The  possibility  of 
apoplexy,  uremia,  or  heart  failure  must  be  borne  in  mind,  and  yet 
such  patients  not  infrequently  make  perfect  recoveries.  Blood- 
pressure  readings  alone  cannot  be  used  as  a  criterion  of  safety;  the 
patient's  general  condition  must  be  carefully  considered.  Cases 
of  arterial  hypotension,  especially  if  this  condition  is  associated 
with  lymphocytosis  and  other  evidences  of  status  lymphaticus, 
withstand  anesthesia  as  badly  as  they  do  infectious  disease. 

"The  practical  surgeon  should  have  knowledge  of  the  following 
data :  The  effect  of  the  general  narcotic  on  blood-pressure  and  its 
relation  to  shock;  whether  in  certain  operations  shock  is  less  if 
the  operation  is  carried  on  under  spinal  or  local  anesthesia,  the 
effect  of  hemorrhage,  the  duration  of  the  operation,  exposure  of 
the  tissues  to  the  air,  effects  of  extreme  heat  or  cold,  the  effect  of 
manipulation  or  injury  in  various  tissues  or  organs"  (Bloodgood). 
While  the  manipulation  of^  sensitive  organs  causes  a  primary  rise 
of  pressure,  such  a  procedure  may  go  far  toward  exhausting  the 
vasomotor  centre. 

Surgical  Shock. — Surgical  shock  has  been  described  as  "a  state 
of  general  apathy,  reduced  sensibility,  extreme  motor  weakness, 
great  pallor,  very  small  pulse,  thready  soft  arteries,  irregular  gasping 
respirations,  and  subnormal  temperature."^  There  is  perhaps  no 
subject  in  the  whole  domain  of  surgery  regarding  the  pathology 
of  which  more  radical  differences  of  opinion  exist  than  shock. 

1  Meltzer,  S.  J.:    The  Nature  of  Shock,  Arch.  Int.  Med.,  July,  1908,  p.  571. 


SURGICAL  SHOCK  397 

This  is  at  least  in  part  due  to  the  fact  the  term  shock  is  appHed  to 
various  conditions  which  may  arise  from  trauma,  intoxications, 
hemorrhage,  etc.  It  has  been  suggested  (Mann)  that  the  term 
"shock"  (similarly  to  the  much  abused  and  too  inclusive  term  of 
"rheumatism"  should  be  dropped,  or  if  used  at  all,  be  limited  to  a 
condition  in  which  without  demonstrable  hemorrhage  the  amount 
of  circulating  fluid  has  been  greatly  diminished  owing  to  venous  or 
capillary  stasis,  or  to  exudation  of  serum  or  the  diapedesis  of 
corpuscles. 

Since  the  publication  of  Crile's  work  on  blood-pressure  in  relation 
to  surgical  shock,  the  view  that  this  condition  is  the  result  of  an 
exhaustion  of  the  vasomotor  centres  has  been  widely  accepted.  Crile 
originally  stated  that  "neither  the  heart  muscle,  nor  the  cardiac 
centres,  nor  the  respiratory  centre,  are  other  than  secondarily 
involved."^  Collapse  is  due  to  a  suspension  of  the  function  of  the 
cardiac  or  of  the  vasomotor  mechanism  or  to  hemorrhage.  These 
statements  are  based  upon  investigations  of  a  large  amount  of  clin- 
ical and  experimental  material  which  seemed  to  show  that  (1)  the 
only  constant  finding  in  cases  of  shock  was  a  fall  of  blood-pressure; 
(2)  there  were  no  constant  demonstrable  lesions  in  the  circulatory 
apparatus;  (3)  the  fall  of  pressure  was  not  due  to  exhaustion  of 
the  peripheral  nerve  vascular  mechanism ;  (4)  that  cocainization  or 
destruction  of  the  vasomotor  centres  produces  a  fall  of  pressure  to 
the  shock  level ;  (5)  that  drugs  or  other  methods  of  treatment  which 
raised  arterial  pressure  were  beneficial,  whereas  other  stimulants 
which  were  employed  were  either  useless  or  definitely  detrimental. 
According  to  this  hypothesis,  then  shock  is  due  to  an  exhaustion 
of  the  vasomotor  centre  resulting  from  centripetal  sensory  stimuli. 

Muns^  regards  the  symptom-complex,  known  as  postoperative 
shock,  as  a  combination  of  the  effects  of  excitation  and  depression, 
which  varies  directly  with  the  algebraic  sum  of  these  two  factors, 
"  The  vasomotor  centre  is  the  variable  factor  in  bringing  about  the 
vasomotor  chainge;  the  variation  of  response  is  directly  dependent 
upon  the  changes  in  the  vasomotor  centre  produced  by  ether. 

In  shock  we  find  the  diastolic  pressure  decreased,  the  pulse  rate 
and  the  pulse-pressure  increased.  When  cardiac  exliaustion  occurs 
the  systolic  pressure  falls  toward  the  diastolic  level  until  the  pulse- 
pressure  becomes  so  small  that  the  cardiac  and  respiratory  centres 
are  no  longer  sufficiently  supplied  with  blood  and  death  occurs. 

1  Crile,  G.  W.:   Blood-pressure  in  Surgery,  Philadelphia,  1903. 
'  Blood-pressure  and  Graphic  Vasomotor  Changes  in  the  Periphery  during  Ether 
Anesthesia,  Ann.  Surg.,  1916,  Ixiv,  645. 


308      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

"A  respiratory  rate  of  more  than  30  per  minute  is  too  rapid  to 
assist  in  moving  the  blood,  thus  throwing  the  whole  burden  upon 
the  heart"  (McKesson). 

The  experiments  of  Porter^  and  of  Seelig  and  Joseph^  have  shown 
conclusively  that  the  depression  or  fatigue  of  the  vasomotor  centre 
can  no  longer  be  considered  as  the  primary  cause  of  shock.  Nor 
has  it  been  demonstrated  that  the  peripheral  bloodvessels  constantly 
or  uniformly  lose  their  tone.  Mann^  found  that  no  amount  of  sensory 
stimulation  would  produce  shock  in  the  anesthetized  animals  so  long 
as  the  abdomen  is  not  opened  and  hemorrhage  is  prevented. 

Shock  may  be  due  to  mechanical  causes.  The  studies  of  Jane  way 
and  Jackson''  showed  that  shock  may  be  produced  by  partial, 
controllable  occlusion  of  the  inferior  vena  cava.  The  blood  supply 
of  the  heart  is  thus  diminished  and  arterial  pressure  falls.  Even 
if  the  constriction  is  relieved  and  arterial  pressure  in  part  restored, 
death  may  later  ensue  in  consequence  of  vascular  changes — loss  of 
tone — in  the  splanchnic  capillaries  and  venules.  According  to  this 
conception  shock  is  a  condition  in  which  there  has  been  a  general 
displacement  of  a  critical  quantity  of  blood  from  the  arterial  to  the 
capillary  and  venous  portions  of  the  circulation. 

Crile^  believes  that  the  essential  lesions  of  shock  are  in  the  brain 
cells  and  are  caused  by  the  conversion  of  potential  energy  in  the 
brain  cells  into  kinetic  energy  at  the  expense  of  certain  chemical 
compounds  stored  in  the  cells.  As  a  result  of  certain  noci  imjmlses 
(fear,  exhaustion,  anesthesia,  insomnia,  etc.),  the  brain  threshold  is 
lowered  arid  the  trauma  of  operation  or  injury  may  produce  the 
shock.  In  ordef  to  avoid  shock  it  is  necessary  to  exclude  these  noci 
impulses  both  of  the  special  senses  and  of  common  sensation.  The 
technic  of  anoci-association  consists  briefly  in  excluding  all  psychic 
stimuli  by  proper  preoperative  care  of  the  patient,  protecting  the 
brain  against  destructive  psychic  strain  during  the  operation  by 
complete  anesthesia  and  preventing  nerve  trauma  by  blocking  the 
nerves  with  local  anesthetics.  Crile  lays  the  greatest  stress  on  the 
psychic  element,  a  conception  which  is  not  essentially  at  variance 
with  Henderson's  theory. 

'  The  Relation  of  Afferent  Impulses  to  the  Vasomotor  Centres,  Am.  Jour.  Physiol., 
1910,  xxvii,  276;  and  The  Vasotonic  and  Vasoreflex  Centre,  ibid.,  1915,  xxxvi,  418. 

^  Vasoconstrictor  Centre  during  the  Development  of  Shock,  Jour.  Lab.  and  Clin. 
Med.,  February  1,  1916,  No.  5. 

'  The  Peripheral  Origin  of  Shock,  Bull.  Johns  Hopkins  Hosp.,  1914,  xxv,  205. 

*  The  Distribution  of  the  Blood  in  Shock,  Proc.  Soc.  Exp.  Biol,  and  Med.,  1915, 
xii,   193. 

*  The  Kinetic  Theory  of  Shock  and  its  Prevention  through  Anoci-association 
(Shockless  Operation),  Lancet,  July  5,  1913,  p.  7. 


SURGICAL  SHOCK  399 

Yandell  Henderson/  on  the  other  hand,  believes  that  shock 
results  from  a  lack  of  fluid  in  the  circulation.  According  to  this 
view  there  is  a  loss  of  CO2  from  the  blood  (acapnia)  which  results 
from  increased  respiration  due  to  pain,  trauma,  fever,  acidosis, 
exposure  of  tissues,  or  maladministration  of  the  anesthetic.  This 
causes  a  diminution  of  hemic  osmotic  tension,  increased  fluid 
transudation  to  the  tissues,  and  a  decrease  in  the  total  volume  of 
blood.  Owing  to  a  fall  of  venous  pressure  the  heart  is  no  longer 
adequately  filled  with  blood,  and  hence  the  systolic  output  dimin- 
ishes, and  a  condition  analogous  to  hemorrhage  ensues.  The  experi- 
ments of  Morison  and  Hooker^  indicate  that  loss  of  venous  tone, 
causing  a  stagnation  of  blood  in  the  veins  and  an  insufficient  filling 
of  the  right  heart  (as  previously  maintained  by  Henderson)  plays 
a  considerable  part.  Mann's  investigations  indicate  that  the  loss 
of  serum  and  erythrocytes  caused  by  handling  of  the  delicate 
vascular  area  of  the  splanchnics  plays  an  important  role. 

"The  clinical  signs  of  shock  which  appear  after  section  of  the 
abdomen  and  exposure  of  the  viscera  are  due  to  a  loss  of  circulatory 
fluid.  This  loss  of  fluid  is  not  dependent  upon  any  primary  impair- 
ment of  the  medullary  vasomotor  centre  and  takes  place  at  a  point 
beyond  the  control  of  the  vasomotor  mechanism.  The  causes 
for  this  loss  of  fluid  are  apparently  the  same  as  those  which  deter- 
mine the  accumulation  of  fluid  in  any  other  irritated  area  and  pro- 
duce the  signs  of  inflammation.  The  nervous  system  probably 
plays  no  greater  part  in  the  former  case  than  in  the  latter.  The 
condition  is  made  grave  when  the  viscera  are  exposed  because  of 
the  great  vascularity  of  the  tissues  involved."^ 

Corbett's*  experiments  led  him  to  conclude  that  shock  is  of  a 
composite  nature,  in  which  epinephrin  exhaustion  and  oligemia  are 
predominating  factors,  while  anesthesia,  pain,  fright  and  trauma 
are  immediate  agents  in  producing  epinephrin  exhaustion  as  well 
as  shock.  Not  "that  epinephrin  loss  is  shock,  but  rather  epinephrin 
is  necessary  to  overcome  shock,  and  anything  that  depletes  epi- 
nephrin favors  the  development  of  that  condition."  "Low  blood- 
pressure  is  a  constant  accompaniment  of  shock,  so  constant,  indeed, 
that  investigators  practically  always  express  the  state  of  shock 
in  terms  of  manometric  pressure."^ 

» Am.  Jour.  Physiol.,  1910,  xxv-ii,  167. 

'  The  Vascular  Tone  and  Distribution  of  the  Blood  in  Surgical  Shock,  Am.  Jour. 
Physiol.,  1915,  xxxvii,  86. 

'  Mann,  F.  C:  Shock  and  Hemorrhage:  An  Experimental  Study,  Surg.,  Gynec. 
and  Obst.,  October,  1915,  p.  430. 

*  The  Suprarenal  Gland  in  Shock,  Jour.  Am.  Med.  Assn.,  1915,  Ixv,  380. 

*  Gray  and  Parsons:  Anis  and  Gale  Lectures,  Royal  College  of  Surgeons  of 
London,  March,  1912,  British  Med.  Jour.,  April  and  May,  1912. 


400      BLOOD-PRESSURE  IN  SURGERY  AMD  OBSTETRICS 

W.  T.  Porter^  who  has  recently  made  an  extensive  study  of  shock 
as  seen  in  modern  warfare,  found  that  low  blood-pressure,  paralysis 
and  other  abnormalities  may  result  in  men  who  are  without 
visible  wounds  from  the  detonation  of  high  explosives.  In  shock  as 
seen  in  the  trenches  ''there  isno  essential  difference  between  the 
low  pressure  of  men  and  that  of  other  animals."  When  the  diastolic 
pressure  falls  to  60  mm.  or  less  shock  is  imminent,  and  when  it 
reaches  45  to  50  mm.,  recovery  does  not  occur  without  aid.  Accord- 
ing to  Porter's  observations  one  should  prevent  the  occurrence  of 
splanchnic  stasis  with  its  consequent  disturbance  of  cardiac  activity 
and  nerve-cell  nutrition  by:  (1)  Placing  the  wounded  in  such  a 
position  that  the  abdominal  vessels  will  be  higher  than  the  heart  and 
brain;  (2)  the  application  of  heat;  (3)  intravenous  saline  infusion 
containing  epinephrin;  (4)  blood  transfusion  in  some  cases,  and 
(5)  half-hourly  observations  of  the  diastolic  pressure.  Briscons 
and  Mercier^  state  that  (1)  men  knocked  down  by  shell 
explosions  have  a  rapid  pulse  and  lower  diastolic  pressure  similar 
to  those  visibly  wounded.  (2)  Concussion  alone  accelerates  the 
pulse  but  lowers  the  pressure  far  less.  (3)  Mere  emotional  stress, 
despite  polypnea  and  other  symptoms  produces  but  little  disturb- 
ance of  either  pulse  or  blood-pressure.^ 

In  the  early  stages  of  shock  a  marked  rise  of  pressure  often  occurs 
as  the  result  of  stimuli  which  exert  a  vasoconstrictor  influence,  but 
owing  to  continuous  stimulation  of  this  kind  a  stage  of  depression 
occurs  which  may  result  in  death. 

Hemorrhage  is  an  important  contributing  factor  in  the  produc- 
tion of  shock,  and  all  avoidable  bleeding  should  be  promptly 
checked.  Sudden  or  large  hemorrhage  manifests  itself  by  a  fall  of 
blood-pressure.  A  rapid  and  persistent  fall  of  pressure  with  an 
increased  pulse  rate  indicates  a  loss  of  blood  too  great  for  the 
organism  to  compensate  for  by  peripheral  vasoconstriction  and  by 
an  additional  expenditure  of  cardiac  energy.  The  diastolic  lyressure 
is  an  index  of  far  greater  importance  than  the  systolic,  and  a  diastolic 
pressure  of  50  mm.  seems  to  be  the  lowest  pressure  at  which  the 
circulation  can  be  maintained.    (See  Hemorrhage,  p.  394.)^    Rough 

1  Shock  at  the  Front,  Boston  Med.  and  Surg.  Jour.,  1916,  pp.  175,  854. 

«  Bull,  de  I'Acad.  de  M6d.,  November  21.  1916. 

3  For  a  more  detailed  discussion  of  shock  see  Parham,  F.  W. :  Shock,  Its  Nature 
and  Management,  South.  Med.  Jour.,  1913,  vi,  763.  See  also  J.  M.  Wainwright: 
The  Present  Status  of  Our  Knowledge  of  Shock,  Penn.  Med.  Jour.,  December,  1914, 
p.  180.  Gwathmey:  Anesthesia,  New  York,  1911.  Bloodgood,  J.  C:  Prog.  Med., 
December,  1914. 

*  Balard,  B. :  La  Tension  Artfirielle  Minima  Element  de  Prognostic  des  Hemor- 
rhages Graves  de  la  Grossesse,  Arch.  Mens.  d'Obst.  et  de  Gyn.,  1914,  iii,  241. 


SURGICAL  SHOCK  401 

manipulation,  tearing  of  the  tissues,  especially  when  these  have  a 
large  afferent  nerve  supply,  must  be  avoided.  "  During  the  opera- 
tion the  amount  of  anesthetic  should  be  as  small  as  possible,  the 
operation  should  be  performed  as  quickly  as  is  compatible  with  the 
safety  of  the  patient  and  the  purpose  of  the  intervention;  tissues 
should  be  handled  as  gently  as  possible;  if  large  nerves  must  be 
divided,  as  in  amputations,  they  should  be  blocked  with  cocain 
injection;  tissues  should  be  exposed  to  air  only  when  absolutely 
necessary;  they  should  be  protected  with  warm,  moist  gauze;  the 
patient  should  not  be  exposed  to  extremes  of  heat  or  cold.  The 
weaker  the  patient  to  be  subjected  to  operation,  the  more  attention 
must  be  given  to  these  details  which  lessen  shock. "^  Complicating 
factors  such  as  anemia,  nephritis,  diabetes,  alcoholism,  acute  and 
chronic  infections,  metabolic  disturbances,  and  ps\'chic  factors  must 
also  be  borne  in  mind. 

The  handling  of  tissues  and  organs  supplied  with  sensory  nerves 
by  the  cerebrospinal  system  is  more  apt  to  induce  shock  than  is 
the  manipulation  of  those  whose  nerve  supply  is  derived  from  the 
sympathetic  nerves  or  the  lower  vagus.  Furthermore,  inflammation 
enhances  the  sensibility.  Tumors  are  said  to  be  insensible,  but  their 
connection  with  other  tissues  must  be  borne  in  mind. 

The  Treatment  of  Shock. — The  keynote  of  treatment  lies  in 
prevention  which  has  already  been  considered.  The  arterioles  and 
veins  once  they  are  relaxed,  do  not  readily  regain  the  tonus.  Hence 
the  pressure  required  to  keep  up  the  circulation  in  the  medulla  and 
in  the  coronary  arteries  must  be  produced  by  increased  cardiac  work. 
Drugs  are  for  the  most  part  unsatisfactory. 

The  most  rational  therapeusis  of  shock  consists  in  the  slow  and 
prolonged  intravenous  administration  of  pituitrin  or  epinephrin 
in  normal  salt  solution.  The  amount  of  infusion  necessary  may  be 
gauged  by  blood-pressure  readings.  Recent  researches  have  shown 
that  the  intravenous  administration  of  a  molecular  (8.4  per  cent.) 
solution  of  sodium  bicarbonate  produces  a  marked  rise  of  blood- 
pressure,  an  increased  cardiac  amplitude,  and  depth  of  respiration. 
These  effects  are  due  mainly  to  alkalinity,  much  less  to  bulk  and 
hypertonicity,  and  in  part  to  some  other  undetermined  factor  acting 
chiefly  upon  the  heart,  but  not  to  the  increased  carbon  dioxide 
content  of  the  blood.^  When  the  infusion  of  normal  salt  solution  is 
employed  in  the  treatment  of  shock  due  to  hemorrhage,  the  amount 

*  Bloodgood,  J.  C:  Surgical  Shock,  American  Practice  of  Surgery,  Bryant  and 
Buck,  1906,  i,  469. 

-  Selig,  Tierney  and  Rodenbaugh:  Jour.  Am.  Med.  Assn.,  1913,  Ix,  238. 
26 


402      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

of  solution  infused  should  be  in  excess  of  the  amount  of  blood  lost. 
In  severe  cases  Downs^  recommends  50  to  100  c.c.  per  kilogram  of 
body  weight.  Infusion  must  not,  however,  be  too  rapid  lest  cardiac 
embarrassment  result  from  right-sided  hypertension.^ 

Heat  loss  must  be  prevented.  Investigations  have  shown  that 
in  shocked  animals  camphor,  administered  intravenously,  causes 
an  actual  fall  of  blood-pressure.  It  is  more  apt  to  be  efficacious 
when  given  subcutaneously.  Strychnin  likewise  does  not  raise 
blood-pressure,  although  it  may  be  useful  on  account  of  its  stim- 
ulation of  the  nerve  centres.  Nitroglycerin  is  definitely  contra- 
indicated,  although  it  may  temporarily  give  a  better  color  to  the 
skin.  Strophanthin  intravenously  increases  pressure  and  is  often 
useful.  Caffein  intravenously  tends  rather  to  lower  than  to  raise 
blood-pressure.    Atropin  is  often  useful  when  the  skin  is  clammy. 

In  cases  due  to  hemorrhage  Hogan^  advises  the  intravenous 
infusion  of  colloidal  gelatin.  This  solution,  like  blood  serum,  does 
not  so  readily  escape  from  the  bloodvessels  as  does  ordinary  salt 
solution. 

Inversion  of  the  patient  to  increase  blood-pressure  in  the  brain 
should  be  tried,  but  not,  of  course,  if  the  patient  has  already  been 
in  the  Trendelenburg  position.  This  posture  may  cause  arrhythmia 
and,  according  to  Pope,^  even  heart-block,  "due  either  to  acute 
dilatation,  to  toxins,  or  fatigue,  or  sepsis,  or  coronary  clots,  or 
direct  trauma  to  some  area  of  cardiac  reflex."  "  It  is  quite  possible, 
however,  that  from  this  position  slight  edema  or  exudate  into  the 
fourth  ventricle  may  occur  and  may  disturb  the  respiratory  and 
pneumogastric  centres.  In  shock  from  this  cause  Pope  suggests 
venesection  from  the  jugular  vein,  cardiac  massage  and  epinephrin 
in  Ringer's  solution  forced  backward  in  the  arterial  stream,  as 
giving  the  only  possible  chance  for  recovery."^  Atropin,  strychnin, 
or  caffein  in  hypodermic  administration  are  currently  employed. 
The  patient's  head  should  be  kept  low,  the  feet  elevated,  the  body 
warm  and  quiet.  Blood-pressure  may  be  elevated  by  bandaging 
the  extremities.  Fresh  air  should  be  supplied  and  carbon  dioxide 
irt  6  per  cent,  concentration  may  be  tried. 

According  to  Crile's  anoci  hypothesis,®  stimulants  are  contra- 

»  Am.  Jour.  Obst.  and  Dis.  Women  and  Child.,  1916,  Ixxiii. 

*  Simpson,  F.  F.:  Jour.  Am.  Med.  Assn.,  1915,  Ixv,  941. 

» Intravenous  Use  of  Colloidal  (Gelatin)  Solution  in  Shock,  Jour.  Am.  Med.  Assn., 
1915.  p.  721. 

<  California  State  Jour.  Med.,  December,  1913,  p.  499. 
'  Edit.  Jour.  Am.  Med.  Assn.,  1914,  Ixii,  776. 

•  Crile  and  Lower:  Anoci-association,  Philadelphia,  1914. 


SURGICAL  SHOCK  403 

indicated,  while  morphin  and  other  sedatives  may  prove  useful. 
Normal  saline  is  beneficial  temporarily  and  within  limits,  while 
human  blood  may  be  expected  to  yield  the  best  results.  All  author- 
ities are  agreed  that  preventive  measures  are  of  the  greatest  importance. 
Fear  as  usually  encountered  increases  both  pulse  rate  and  blood- 
pressure,  but  in  extreme  degree  blood-pressure  may  fall  within  a 
brief  period  as  much  as  60  mm.  The  elimination  to  the  greatest 
possible  extent,  of  fear  and  anxiety  on  the  part  of  the  patient  before, 
and  in  preparation  for  an  operation  is  of  the  utmost  importance. 
The  patient  should  see  and  hear  as  little  as  possible  of  the  operating 
room  and  of  the  preparations  which  are  being  made  for  the  impend- 
ing operation. 

Struggling,  and  pressure  upon  the  abdomen  by  gauze  pads,  ban- 
dages, etc.,  may  cause  cardiac  dilatation.  The  administration  of 
morphin  in  moderate  doses  preceding  the  administration  of  ether 
is  often  advisable.  It  diminishes  the  amount  of  ether  required, 
tends  to  prevent  struggling,  excitement,  and  acapnia,  and  in  man 
does  not  impair  vasomotor  tone.  Patients  with  heart  disease, 
pneumonia,  or  empyema  should  be  anesthetized  gradually,  in  the 
sitting  or  semirecmnbent  posture  (Gatch,  Gann,  and  Mann).^ 

The  Posture  of  the  Patient. — The  posture  of  the  patient  during 
operations  of  necessity  entails  marked  changes  in  blood-pressure 
and  blood  distribution,  with  which  the  heart  under  the  benumbing 
influence  of  anesthesia  or  if  handicapped  by  disease,  may  be  unable 
to  cope.  Thus  in  the  morphinized  animal  carotid  pressure  falls 
owing  to  this  effect  of  gravity  in  the  head-up  posture,  and  rises 
when  the  feet  are  uppermost.  Compensation  is  established  by 
cardiac  and  vasomotor  reactions  in  the  stronger  animals,  but 
rabbits  die  if  the  feet-down  position  is  long  maintained  (fifteen 
minutes  to  two  hours)  from  cerebral  anemia,  due  to  splanchnic 
dilatation  which  can  no  longer  be  overcome  by  respiratory  move- 
ments (abdominal  compression  and  diaphragmatic  suction).  The 
normal  vasomotor  tone  is  depressed  by  ether,  and  especially  so  by 
chloroform.  Again,  dogs  may  be  killed  by  a  prolonged  Trendelen- 
burg position  plus  ether  (not  morphin)  anesthesia,  the  death 
resulting  from  failure  of  respiration,  the  heart  action  remaining 
good  and  the  blood-pressure  high.  While  death  may  occur  similarly 
in  the  horizontal  position,  partial  or  complete  respiratory  failure 
is  more  common  in  the  head-dowTi  posture. 

>  The  Danger  and  Prevention  of  Severe  Cardiac  Strain  during  Ether  Anesthesia, 
Jour.  Am.  Med.  Assn.,  1913,  Ix,  1273. 


404      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

Recent  researches  indicate  that  "the  Trendelenhurg  position  is 
harmless  for  patients  with  normal  hearts,  provided  that  respiration 
is  free  and  unobstructed."  This  "position  should  be  used  only 
with  extreme  caution  in  cases  of  cardiac  diseased  The  position 
should  not  be  established  or-  relinquished  suddenly.  Using  this 
posture  forces  a  large  amount  of  venous  blood  toward  the  heart, 
and,  if  this  organ  is  capable  of  handling  it,  produces  temporarily 
a  marked  increase  of  brachial  blood-pressure.  If  the  position  is 
suddenly  abandoned  the  venous  pressure,  and  consequently  the 
arterial  pressure,  fall  and  bulbar  anemia  may  result,  especially 
if  vascular  tone  is  depressed. 

The  Effect  of  Chilling  during  Anesthesia. — Under  ether  anesthesia, 
the  application  of  cold  to  dogs  produces  a  marked  rise  of  blood- 
pressure;  under  chloroform  no  such  rise  occurs.  It  seems,  therefore, 
that  the  narcotic  dose  of  ether  does  not  abolish  vasomotor  reflexes 
as  does  chloroform.  The  rise  of  pressure  in  the  former  instance 
causes  a  congestion  of  the  internal  viscera,  a  condition  comparable 
to  what  occurs  during  the  act  of  "catching  cold,"  and  probably 
accounts  for  the  greater  frequency  of  respiratory  infections  after 
ether.  ^ 

Visceral  Manipulation. — Blood-pressure  observations  have  taught 
the  importance  of  avoiding,  or  at  least  minimizing,  certain  surgical 
manipulations.  Thus  a  marked  fall  of  pressure  is  caused  by  irrita- 
tion of  the  dura  and  of  the  subdiaphragmatic  peritoneum,  traction 
upon  bloodvessels  or  nerves,  renal  or  mesenteric  vessels,  the  brachial 
plexus,  or  the  testicles;  by  rough  sponging,  blunt  dissection,  exposure 
or  rough  handling  of  viscera,  peritoneal  flushing,  separating  adhe- 
sions, delivering  tumors,  extirpation  of  the  kidney,  exposure  of  the 
spinal  cord,  section  of  large  nerve  trunks  unless  previously  cocainized. 
The  upper  portion  of  the  peritoneal  cavity  is  more  sensitive  than 
the  lower. 

On  the  other  hand,  hlood-yress^tre  rises  during  divulsion  of  the 
sphincter  ani  and  in  stretching  of  the  sciatic  nerve. 

The  following  procedures  produce  but  slight  blood- pressure 
changes:  incision  of  the  scalp,  chiselling  of  bone,  separation  of 
the  periosteum,  hernia  operations  (without  adhesions),  the  resection 
of  ribs,  appendectomy  (simple),  incision  of  the  kidney.  Dragging 
upon  the  mesentery  produces  a  much  greater  fall  of  pressure  than 
handling  the  omentum.      Especial  care  should  be  exercised  in  the 

*  Stursberg:  Das  Verbal  ten  d.  Blutdrucks  unter  d.  Einwirk.  v.  Temperatuireizen 
in  Aether  u.  Chloroform  Narkose.,  Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1910, 
xxii,  1. 


MANIPULATION  OF  THE  PELVIC  VISCERA  405 

region  of  the  duodenum,  pylorus  and  gall-bladder,  owing  to  the 
possibility  of  interfering  with  the  circulation  in  the  larger  venous 
trunks.  Trauma  to  the  pelvic  viscera,  on  the  other  hand,  has  much 
less  tendency  to  produce  shock  (Gatch).  Under  normal  circum- 
stances the  diaphragm  materially  aids  the  circulation  by  alternately 
increasing  the  pressure  in  the  thoracic  and  in  the  abdominal  cavities. 
But  once  the  abdomen  is  opened,  the  diaphragm  no  longer  increases 
intra-abdominal  pressure  during  inspiration  and  hence  less  blood 
reaches  the  right  heart. 

Concussion  of  the  brain  produces  a  fall  of  blood-pressure,  com- 
pression, a  rise  (see  page  389),  but  severe  experimental  injury  of  the 
cerebral  hemispheres  under  complete  anesthesia  does  not  cause 
a  fall  of  pressure.  "  Collapse  from  interference  with  the  medullary 
centres  is  of  course  not  true  surgical  shock"  (Crile). 

Manipulations  of  the  Thoracic  Viscera. — The  effects  of  various 
surgical  manipulations  upon  the  blood-pressure,  pulse  rate,  and 
respiration  have  been  made  by  Flint. ^ 

The  detailed  results  cannot  be  given  here,  but  the  conclusions 
reached  show  that  "the  reactions  of  the  medullary  centres  to 
operative  traumatism  as  shown  in  these  experiments  suggest  that 
we  should  be  cautious  in  the  treatment  of  the  imrietal  lAeura, 
particularly  in  tearing  it  at  the  angles  of  the  intercostal  wound  by 
injudicious  application  of  the  rib-spreader.  The  lungs  may  be 
handled  freely,  but  manipulations  that  tend  to  transmit  traction, 
to  the  great  vessels  and  bronchi  at  the  root  of  the  lung  should  be 
reduced  to  a  minimum.  In  heart  suture  the  Sauerbruch  method 
of  temporary  hemostasis  leads  to  too  serious  a  fall  in  blood-pressure 
to  be  safe  except  where  other  means  of  hemostasis  fail.  Any 
mechanical  stimulation  of  the  heart,  either  directly  or  through  the 
pericardium,  during  suture,  should  be  avoided  so  far  as  possible. 
Furthermore,  in  packing  off  the  lungs  to  obtain  an  exposure  of 
other  thoracic  viscera  it  would  be  wise  to  avoid  any  unnecessary 
trauma  which  might  tend  to  reduce  the  blood-pressure  excessively. 
These  are  the  stimuli  which,  in  the  present  set  of  experiments, 
have  produced  the  most  serious  reactions." 

Manipulation  of  the  Pelvic  Viscera. — Manipulation  of  the  pelvic 
organs  during  laparotomies  may  produce  either  a  rise  or  a  fall  of 
pressure,  depending  upon  the  manner  in  which  the  viscera  are 
handled.  Experimental  irritation  of  the  genital  mucous  membrane 
(in  dogs)  produces  a  fall  of  pressure  ranging  between  5  and  50 

'Flint,  J.  M.:  Physiological  Basis  of  Thoracic  Surgery,  Jour.  Am.  Med.  Assn., 
1912,  lix,  760. 


40G      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

per  cent.  The  fall  of  pressure  is  more  marked  if  the  stimulation 
is  applied  in  the  lower  vagina;  in  the  upper  portion  a  rise  of  pressure 
may  result.    Irritation  of  the  rectal  mucosa  causes  a  fall  of  pressure.^ 

Schroder  found  that  manipulations  of  the  female  generative 
organs  by  way  of  the  vagina  caused  less  lowering  of  pressure  than 
when  a  laparotomy  was  performed;  but  Crile  found  that  manipu- 
lation always  produced  a  rise  which  was  proportional  to  the 
traumatism. 

Aspiration  of  the  Pleura. — Pleural  effusions,  if  large  in  amount, 
tend  to  raise  blood-pressure,  unless  sufficiently  large  to  cause  cardiac 
embarrassment.  The  increase  in  pressure,  which  is  greater  than  in 
abdominal  effusions,  may  amount  to  20  mm. 

Vertigo,  syncope,  and  even  death  may  follow  the  withdrawal 
of  fluid  from  the  pleural  cavity.  It  has  been  shown  that  these 
effects  are  not  merely  the  result  of  altered  pressure  relations  in  the 
thorax,  but  that  they  are  due  to  a  depressor  reflex  originating  in 
the  pleura,  which  may  be:  (1)  A  central  reflex  cardio-inhibitory 
type,  in  which  the  heart  is  slow,  intermittent,  and  there  are  great 
variations  in  the  systolic  and  diastolic  pressures,  associated  with 
slow  respirations.  (2)  A  vasomotor  type  showing  a  steady  rapid 
decline  of  pressure  without  any  great  difference  between  the  systolic 
and  the  diastolic  readings.  Respirations  are  shallow,  sometimes 
rapid.  This  type,  in  contradistinction  to  the  first,  not  infrequently 
terminates  in  death.  The  reflex  may  be  either  central  or  peripheral. 
To  minimize  the  likelihood  of  these  accidents  care  should  be  taken 
to  avoid  irritating  the  pleura  with  the  trocar  or  drainage  tube.^ 
In  seven  out  of  eight  aspirations  Clark  found  a  fall  of  venous  'pressure 
(see  page  230). 

Paracentesis  Abdominalis. — This  procedure  is  attended  with 
much  the  same  blood-pressure  changes  as  those  which  occur  when 
the  pleura  is  aspirated.  As  might  be  expected  a  greater  fall  (32  mm. 
on  the  average)  occurs. 

"Up  to  a  certain  point  the  general  arterial  pressure  increases 
with  an  increase  in  the  pressure  of  intra-abdominal  fluid;  beyond 
this  point  the  blood-pressure  falls.  Quirin  attributes  the  early 
rise  in  blood-pressure  to  increased  resistance  by  compression  to 
the  flow  of  blood  through  the  abdominal  arteries;  the  fall  occurs 
when  the  heart,  handicapped  by  a  diminished  supply  of  venous 

1  Belfield,  W.  J.:  Ueber  depressonsche  Reflexe,  erzengt  durch  Schleimhautreit- 
zung,  Arch.  f.  Anat.  u.  Phys.,  1882,  p.  198. 

'  Capps  and  Lewis:  Blood-pressure  Lowering  Reflexes,  Am.  Jour.  Med.  Sc,  1907, 
cxxxiv,  868. 


CATHETERIZATION  OR  DRAINAGE  OF  THE  BLADDER     407 

blood,  is  no  longer  able  to  overcome  the  resistance  of  the  abdominal 
arteries.  Ascitic  fluids  have  an  intra-abdominal  pressure  of  19  to 
42  mm.  Hg.,  according  to  Quincke.  Quirin  found  that  the  intra- 
abdominal pressure  fell  10  to  14  mm.  after  tapping,  and  that  this 
corresponded  with  the  simultaneous  fall  in  arterial  pressure  of  5 
to  10  mm.  Hg.  after  paracentesis  in  four  cases.  Cook  and  Briggs 
record  one  case  of  abdominal  paracentesis  in  which  the  pressure 
fell  35  mm.  Hg.  during  the  withdrawal."^ 

The  rate  of  withdrawal  is  apparently  more  important  than  the 
amount  so  far  as  the  immediate  pressure  is  concerned.  The  ultimate 
pressure  depends  more  upon  the  quantity  of  fluid  withdrawn. 
External  abdominal  pressure  favors  a  rise  of  pressure,  as  does 
also  the  recumbent  posture.  "Improvement  is  most  pronounced 
in  those  cases  that  undergo  a  marked  fall  in  pressure  during  the 
operation"   (Capps). 

The  emotional  disturbance  entailed  by  a  prospective  operation, 
as  well  as  the  actual  pain  of  puncture,  produce  a  temporary  eleva- 
tion of  blood-pressure  (see  under  Abdominal  Distention  and  Blood- 
pressure,  page  268). 

The  majority  of  surgeons  seem  to  be  impressed  with  the  impor- 
tance of  blood-pressure  readings  in  brain  surgery.  Horsley  states 
that  25  per  cent,  of  the  sudden  deaths  after  prolonged  operation 
may  be  avoided  by  frequent  observations. 

Catheteiization  or  Drainage  of  the  Bladder. — Drainage  of  the 
bladder,  either  by  suprapubic  incision  or  by  a  retained  catheter  as  a 
preliminary  procedure  to  prostatectomy,  definitely  lowers  blood- 
pressure  (average  in  50  cases,  166  to  145  mm.)  and  diminishes 
mortality.^  Peacock^  says  that  in  cases  of  chronic  prostatic  obstruc- 
tion, serious  back  pressure  upon  the  renal  circulation  exists. 
Increased  blood-pressure  is  a  compensatory  phenomenon  necessary 
to  maintain  urinary  secretion  against  back  pressure.  A  sudden 
relief  of  vesical  pressure,  whether  a  result  of  catheterization  or 
cystotomy,  causes  a  prompt  and  marked  fall  of  blood-pressure 
(20  to  100  mm.).  This  may  result  in  anemia  or  uremia.  To  this 
"hidden  nephritis,"  which  occurs  in  from  25  to  50  per  cent,  of 
operative  prostatectomies,  rather  than  to  shock  or  hemorrhage, 
he  attributes  the  high  mortality  with  which  the  operation  is  asso- 
ciated.   He  further  suggests  that  the  foregoing  phenomena  explain 

'  Capps,  J.  A. :  Some  Observations  on  the  Effect  on  the  Blood-pressure  of  the 
Withdrawal  of  Fluid  from  the  Thorax  and  Abdomen,  Jour.  Am.  Med.  Assn.,  January 
5,  1907,  xlviii. 

2  Balfour,  D.  C:  Mayo  Clinic,  1913,  p.  73. 

'  Blood-pressure  and  Prostatectomy,  Ann.  Surg.,  1916,  Ixiv,  659. 


408      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

the  advice  never  to  empty  a  distended  bladder  completely,  since 
shock  and  even  death  may  follow  a  simple  catheterization.  A  pre- 
operative pressure  much  above  150  mm.  markedly  increases  the 
risk  entailed  in  cystotomy  or  prostatectomy. 

Anesthetics.— Anesthetics    diflFer    in    their    effect    upon    blood- 
pressure,  and  the  degree  to  which  a  given  drug  lowers  pressure  is 
an  index  of  the  danger  with  which  its  administration  is  associated. 
Ether. — The  early  stages  of  ether  anesthesia  are  associated  with 
an  increased  blood-pressure  due  to  psychic  stimuli  and  muscular 
effort.    This  increased  pressure  is  maintained  through  stimulation 
of  the  respiratory  centre.    Recent  experimental  evidence  has  shown 
that  ether  alone,  even  when  employed  in  large  amounts,  rarely 
produces  much  depression  of  blood-pressure.^     When  anesthesia 
is  complete,  the  pulse  rate  and  the  hlood-inessure  ar«  inacticaUy 
normal.    A  slight  postanesthetic  rise  is  often  observed,  which  the 
administration  of  oxygen  generally  increases.     If  the  period  of 
etherization  exceeds  one  hour  more  or  less  peripheral  vasodilatation 
occurs  and  tends  to  progress  as  time  increases.    As  a  general  rule 
the  maximum  is  not  reached  within  seven  hours;  it  may,  however, 
appear  much  sooner. ^    During  ether-oxygen  anesthesia  blood-pressure 
is  invariably  increased.     If  ether  is  administered  intravenously  a 
preliminary  rise  of  pressure  (6  to  25  mm.)  occurs  to  be  followed  at 
the  end  of  from  one  to  three  hours  by  a  fall  of  like  degree  (Honan 
and  Hassler).     A  fall  of  pressure  during  anesthesia  may  result 
primarily  from  either  vasomotor  or  from  cardiac  failure.    Hender- 
son^ believes  that  both  conditions  are  fundamentally  due  to  acapnia 
resulting  from   excessive  pulmonary  ventilation  in  the  stage  of 
excitement.      Prolonged  ether-chloroform  narcosis  in  rabbits  is  said 
to  produce  injury  to  the  chromaffin  system  (Schur  and  Wiesel). 
The  effect  of  morphin  and  ether  anesthesia  combined  differs 
from  that  of  ether  alone.     In  the  latter  instance  sensory  stimuli 
are  not  completely  blocked,  although  the  sensorium  is  abolished  and 
surgical  anesthesia  may  be  sufficient. 

Chloroform. — Blood-pressure  is  often  reduced  even  in  the  earlier 
stages  (15  minutes);  under  full  anesthesia  a  marked  fall  is  often 
present  which  in  fatal  cases  continues  progressively  until  death 
occurs,  due  to  cardiac  depression.    Elven  in  the  earlier  stages,  how- 

'  Guy,  W.,  Goodall,  A.,  lleid,  H.  S.:  Blood-pressure  in  Anesthesia,  Edinburgh 
Med.  Jour.,  1911,  n.  s.,  iii,  126. 

2  Muns,  W.  E.:  Blood-pressure  and  Graphic  Vasomotor  Changes  in  the  Per- 
iphery during  Ether  Anesthesia,  Ann.  Surg.,  1916,  Ixiv,  645. 

'  Primary  Heart  Failure  in  Normal  Subjects  under  Ether,  Surg.,  Gynec.  and  Obst., 
1911.  p.  161. 


ANESTHETICS  409 

ever,  the  heart  may  temporarily  cease  contracting,  owing  apparently 
to  reflex  inhibitory  stimuli  originating  in  the  air  passages.  In  case 
of  a  diseased  heart  the  arrest  may  be  permanent.  The  depressant 
action  of  chloroform  upon  the  heart  is  much  greater  than  that  of 
ether.  Regarding  the  primary  vascular  effect  of  chloroform  there 
is  still  divergence  of  opinion.  Some  investigations  show  an  initial 
rise  of  pressure  due  to  stimulation  of  the  vasomotor  centre.  This 
stimulation  does  not  increase  blood-pressure,  as  it  is  more  than 
counter-balanced  by  cardiac  weakness  (Cushny).  l^nlike  ether, 
chloroform  does  not  have  any  compensatory  stimulating  action 
to  mask  the  effects  of  peripheral  stimulation;  it  is  this  property 
which  constitutes  its  danger  (G.  Miiller).  If  oxygen  is  combined 
with  chloroform  blood-pressure  is  much  less  reduced  than  by 
chloroform  alone. 

Ethyl  Chloride. — The  effect  of  ethyl  chloride  upon  the  heart  muscle, 
similarly  to  that  of  chloroform,  is  depressive,  but  nineteen  times 
more  of  the  former  is  required  to  produce  similar  results.  Ethyl 
chloride  causes  local  peripheral  dilatation.  Vagus  inhibition  of  the 
heart  occurs  readily.  In  concentration  of  from  10  to  20  per  cent, 
a"  fall  of  blood-pressure  results  from  vagus  stimulation.  If  30  per 
cent,  or  more  is  used,  blood-pressure  falls  from  cardiac  muscular 
depression,  although  this  is  not  so  pronounced  as  after  chloroform.^ 
Ethyl  chloride  generally  slows  the  pulse  and  produces  a  fall  of 
blood-pressure.2  It  is  by  many  regarded  as  a  dangerous  anesthetic, 
far  inferior  to  nitrous  oxide. 

Nitrous  Oxide. — The  administration  of  this  drug  is  attended  with 
a  slowing  of  the  pulse  and  a  marked  rise  of  arterial  pressure.  These 
effects  have  been  attributed  both  to  a  specific  action  and  to  the 
asphyxial  condition  of  the  blood.  In  arteriosclerosis,  especially  if 
associated  with  hypertension,  it  may  cause  vascular  rupture.  Crile 
states  that  "under  approximately  equal  trauma  the  changes  in 
the  brain  cells  were  approximately  three  times  as  great  under 
ether  anesthesia  as  under  nitrous  oxide  anesthesia;  that  the  fall 
in  the  blood-pressure  was  on  the  average  two  and  a  half  times 
greater  under  ether  than  under  nitrous  oxide;  and  finally,  that  the 
condition  of  the  animal  was  better  after  trauma  under  nitrous 
oxide  than  after  equal  tramna  under  ether." 

When  nitrons  oxide  oxygen  is  used,  the  primary  rise  is  followed  by 
a  fall  to  normal  which  can  be  maintained  by  proper  control  almost 

'  Embley:  Proc.  Royal  Soo.,  1906;  Lancet,  April  20,  1907;  Pharm.  Jour.,  xxiv,  650. 
*  McCardie:     The  Position  of  and    Mortality   from   Ethyl  Chloride  as  a  General 
Anesthetic,  British  Med.  Jour.,  March  17,  1906,  p.  616. 


410      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

indefinitely.  A  sudden  increase  of  oxygen  or  cessation  of  the 
anesthetic  causes  a  marked  rise  lasting  from  five  to  fifteen  minutes 
after  the  return  to  consciousness  (Faught). 

Bloodgood^  states  that  the  average  initial  rise  ranges  between 
5  and  15  mm.  Even  in  cases  of  arterial  hypertension  this  anesthetic 
is  considered  safe. 

Morphin  and  Hyoscin. — These  drugs  are  frequently  employed 
hypodermically  before  the  administration  of  nitrous  oxid-oxygen 
anesthesia.  The  general  result  according  to  McKesson^  is  a  lowering 
of  pressure — 5  to  15  mm. — below  the  patient's  normal;  especially 
is  this  noticeable  in  hypertensive  cases. 

Cocain. — Cocain  stimulates  the  heart  muscle  directly  or  as  the 
result  of  accelerator  influence.  In  the  early  stages  of  intoxication 
there  is  peripheral  vasoconstriction  (local  action  and  central  stimu- 
lation) causing  a  rise  of  blood-pressure.  Later,  pressure  falls 
owing  to  peripheral  action.  Cocain  has  been  almost  entirely 
supplanted  by  the  less  toxic  drugs,  sto\'tiin  and  novocain,  the  former 
being  used  for  spinal  and  the  latter  for  local  anesthesia. 

The  subject  of  anesthesia  cannot,  of  course,  receive  prolonged 
consideration  here,  but  a  few  points  may  be  emphasized.  There 
seems  to  be  no  valid  reason  for  chloroform  as  a  substitute  for  ether 
in  major  operations.  It  should  never  be  administered  after  a 
preceding  period  of  ether  excitement.  For  minor  operations  nitrous 
oxide  is  preferable.  In  using  ether  the  subject  should  be  quickly 
narcotized  and  kept  "well  under."  Struggling  during  the  adminis- 
tration and  incomplete  anesthesia  are  dangerous.  The  beneficial 
effects  of  rebreathing  (CO2  stimulation)  in  preventing  shock,  as 
shown  by  Gatch,  lend  strong  support  to  Henderson's  explanation 
of  this  condition  as  resulting  from  acapnia.  The  preliminary 
administration  of  morphin  is  often  desirable.  Nitrous  oxide  with 
oxygen  is  for  short  operations  an  excellent  anesthetic. 

The  Cerebrospinal  Fluid  and  Blood-pressure.— The  normal 
pressure  of  the  cerebrospinal  fluid  ranges  between  60  and  100  mm. 
H2O.  It  may  be  increased  to  200  to  800  mm.  in  meningitis  or  brain 
tumor.  It  should  never  be  reduced  below  GO  mm.  II2O.  It  varies 
and  is  practically  identical  with  the  pressure  in  the  venous  sinuses.' 
A  relatively  small  increase  in  cerebrospinal   pressure  stimulates 

1  Traumatic  Shock  and  the  Employment  of  Blood-pressure  Estimations  in  Its 
Prevention  and  Treatment,  Internat.  Jour.  Surg.,  1913,  xxvi,  303. 

'  Blood-pressure  under  Anesthesia,  American  Year  Book  of  Anesthesia  and  Anal- 
gesia, 1915,  i,  87. 

'  Frazier  and  Peet:  Factors  of  Influence  in  the  Origin  and  Circulation  of  the 
Cerebrospinal  Fluid,  Am.  Jour.  Physiol.,  1914,  p.  1018. 


CEREBROSPINAL  FLUID  AND  BLOOD-PRESSURE        411 

the  vasomotor,  cardio-inhibitory  and  respiratory  centres.  When 
pressure  is  increased  considerably  above  the  normal  arterial  pressure, 
respiration  ceases,  and  there  is  an  enormous  rise  of  arterial  pressure 
with  a  slow  pulse.  When  the  cardio-inhibitory  centre  becomes 
exhausted,  blood-pressure  rises  still  higher  owing  to  the  continued 
activity  of  the  vasomotor  centre,  until  the  latter  becomes  par- 
alyzed,^ whereupon  blood-pressure  falls. 

Lumbar  Puncture. — Blood-pressure  is  the  most  valuable  guide 
during  this  procedure.  A  well-marked  fall  of  tension  indicates 
immediate  cessation.  Lumbar  puncture  is  sometimes  followed  by 
sudden  syncope  especially  when  medicinal  substances  are  injected. 
This  may  result  from  (1)  the  puncture  of  the  dura — a  rare  but 
possible  reflex  disturbance;  (2)  increased  intraspinal  pressure;  (3) 
the  introduction  of  chemicals  used  for  purposes  of  medication  or 
for  the  preservation  of  sera.  Auer's  researches  indicate  that  tri- 
cresol, which  is  used  for  the  last-named  purpose,  causes  a  greater 
fall  of  blood-pressure  than  chloroform  or  formalin. 

"1.  The  puncture  of  the  skin  is  accompanied  by  a  rise  in  blood- 
pressure  which  varies  in  extent  with  the  degree  of  consciousness, 
the  pain,  and  the  disturbance  produced  by  the  operation,  but  which 
is  not  accounted  for  entirely  by  these  factors.  Puncture  of  the 
dura  causes  a  much  larger  rise,  which  is  due  not  to  pain  or  the 
disturbance  produced  but  to  a  definite  effect  on  the  vasomotor 
centre.    Similar  rises  occur  in  dogs  under  full  anesthesia. 

"2.  W^ithdrawal  of  cerebrospinal  fluid  per  se  tends  to  lower  the 
blood-pressure,  but  the  net  result  of  lumbar  puncture  is  to  raise  it 
for  at  least  twenty  minutes  afterward. 

"3.  The  type  of  blood-pressure  chart  obtained  in  lumbar  punc- 
ture, when  the  increased  intracranial  pressure  is  of  subtentorial 
origin,  is  the  same  as  that  obtained  in  normal  individuals;  or 
as  that  obtained  when  the  increased  pressure  is  of  supratentorial 
origin;  but  in  the  subtentorial  types  the  variations  are  less  pro- 
nounced. In  subtentorial  cases  the  rise  is  more  sustained."^  Blood- 
pressure  readings  should  always  be  made  during  intraspinous 
medication.  Berghausen^  suggests  that  the  needle  be  left  in  situ 
until  blood-pressure  returns  to  the  same  height  as  that  at  which  it 
was  preceding  the  spinal  puncture.  This  seems  hardly  necessary 
if  the  serum  has  been  given  by  the  gravity  method.    According  to 

'  Dixon  and  Halliburton:  The  Cerebrospinal  Fluid,  Jour.  Physiol.,  1914,  xlviii,  317. 
'  Gray,  H.  T.,  and  Parsons,  L. :  Blood-pressure  Variations  Associated  with  Lumbar 
Puncture  and  the  Induction  of  Spinal  Anesthesia,  Quart.  Jour.  Med.,  1911-12,  v,  339. 
'  Intraspinous  Medication,  New  York  Med.  Jour.,  1914,  c,  lOOG. 


412      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

the  last-named  author  sudden  respiratory  changes  follow  only 
when  blood-pressure  change  has  been  marked — usually  after  a 
fall  of  pressure  (see  Meningitis).  If  collapse  symptoms  occur,  the 
head  should  be  lowered,  the  feet  elevated,  and  ether  and  strychnin 
should  be  given  hypodermically. 

Spinal  Anesthesia. — "1.  Blood-pressure  records  from  cases  of 
high  spinal  anesthesia  show  at  the  outset  an  abnormally  high 
blood-pressure  due  to  mental  anxiety ;  then  a  rise  following  lumbar 
puncture;  next  a  'preliminary  fall,'  followed  by  a  further  more 
marked  'main  fall'  as  the  paralysis  affects  the  thorax.  Finally,  as 
the  paralysis  passes  off,  the  blood-pressure  rises  to  its  original 
values.    The  ' preliminary  fall'  is  due  to: 

"  (a)  Flaccid  paralysis  of  the  abdominal  and  skeletal  muscles. 
"  (6)  Subsidence  of  the  disturbance  caused  by  lumbar  puncture. 
"  (c)  Onset  of  mental  calm,  amounting  possibly  to  sleep. 

"The  '  main  fair  is  due  to  the  thoracic  paralysis,  which  is  not 
compensated  for  by  overaction  of  the  diaphragm,  and  consequently 
the  aspiratory  action  of  the  thorax  is  diminished. 

"2.  Marked  deviations  from  this  common  type  of  chart  are 
due  to: 

"  (a)  Voluntary  inspirations  by  the  accessory  respiratory  muscles, 
and 

"  (b)  To  a  lesser  extent  by  the  activity  of  the  higher  centres. 

"Variations  in  the  pulse  rate  do  not  closely  follow  those  of  the 
blood-pressure,  but  a  certain  degree  of  resemblance  is  often  seen 
owing  to  the  consciousness  of  the  patient. 

"  3.  ^  omiting  during  spinal  anesthesia  is  due  to  thoracic  paralysis, 
which  induces  either: 

"  (a)  Anemia  of  the  medulla. 

"  (6)  Excessive  action  of  the  diaphragm,  which  interferes  with 
the  stomach. 

"4.  Blood-pressure  records  from  cases  of  low  spinal  anesthesia 
show  the  '  preliminary  fall'  but  not  the '  main  fall.'  The  '  preliminary 
fair  in  these  cases  is  due  to: 

"  (a)  Subsidence  of  the  disturbance  caused  by  lumbar  puncture. 

"  (6)  Onset  of  mental  calm. 

"  (c)  In  some  cases  from  the  degree  of  flaccidity  of  the  abdominal 
muscles. 

"5.  In  the  supine  position  there  is  no  stagnation  of  blood  in  the 
great  vessels,  even  when  a  very  high  spinal  anesthesia  is  induced." 

Inasmuch  as  the  normal  blood-pressure  depends  upon  afferent 
and  efferent  pressor  and  depressor  stimuli  it  is  evident  that  serious 


SPINAL  ANESTHESIA 


413 


results  may  follow  the  cutting  off  of  such  impulses,  A  cessation 
of  pressor  impulses,  for  instance,  would  leave  the  effect  of  depressor 
fibers  in  predominance. 

The  question  of  blood-pressure  in  spinal  anesthesia  is  a  complex 
one,  owing  to  the  physiological  action  of  the  substances  employed. 
In  fifty  cases  studied  by  Mori  the  results  were  very  variable  owing, 
it  seemed,  to  the  inconstant  effects  of  cocain,  epinephrin,  and  the 
patient's  psychic  state.^  George  Miiller,  in  Frazier's  Clinic  at  the 
University  of  Pennsylvania,  found  that  lumbar  puncture  caused 
a  marked  elevation  of  the  blood-pressure  not  due  to  the  pain, 
because  it  occurs  even  under  anesthesia.  In  correct  spinal  anesthesia 
the  complete  block  of  peripheral  impulses  makes  the  pressure  curve 
independent  of  the  nature  of  the  operation.     If  the  anesthesia  is 


CASES 

30 
20 
10 

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80       70        60       50       40        30       20        10         0         10        20       30         1 

Fig.  103. — Curve  of  relative  amount  of  rise  or  fall  in  blood-pressure  at  end  of 
operation:  readings  to  left  of  zero,  lowered  after  operation;  to  right,  raised.  (After 
Stanley.) 

allowed  to  extend  upward  it  cuts  off  the  pressor  stimuli  to  the 
splanchnic  area  and  may  produce  the  effect  of  shock,  or  if  it  extends 
still  farther  upward,  respiratory  embarrassment  or  even  paralysis 
may  occur  (see  page  343).  Smith^  states  that  blood-pressure  can 
be  as  profoundly  lowered  by  spinal  anesthesia  as  by  section  of  the 
cervical  cord.  The  greatest  fall  occurs  when  injections  are  made 
in  the  thoracic  region,  at  which  point  the  splanchnic  vasomotor 
fibers  are  given  off.  This  part  of  the  vasomotor  mechanism  is 
first  affected  when  injections  are  made  in  the  lumbar  region.     It 


1  Mori,  M. :  Das  Verhalten  des  Blutdruckes  bei  Lumbalanasthesie,  Deutsch. 
Ztschr.  f.  Chir.,  1904,  Ixxiv,  173. 

*  Blood-pressure  in  Spinal  Anesthesia,  Boston  Med.  and  Surg.  Jour.,  1915,  cxxiii, 
602. 


414      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

appears  that  diffusion  of  the  drug  depends  greatly  upon  the  bulk 
of  the  injection — the  more  fluid  injected,  the  greater  the  diffusion. 
The  most  pronounced  effects  on  blood-pressure  occur  when  epi- 
nephrin  was  used  in  conjunction  with  novocain.  P^fforts  to  raise 
the  fallen  pressure  by  the  intravenous  infusion  of  epinephrin  and 
pituitrin  result  in  only  a  transient  rise. 

In  a  study  of  280  cases  Stanley^  found  that  blood-pressure  was 
more  frequently  lowered  than  raised  by  spinal  anesthesia  produced 
by  tropacocain  hydrochloride.  This  is  shown  by  the  chart  on  page 
413,  from  which  it  will  be  noted  that  the  greatest  fall  of  blood- 
pressure  amounted  to  88  mm.  Hg.,  whereas  the  maximum  rise  was 
equivalent  to  38  mm.  Hg.  Despite  the  fall  of  pressure  the  patients' 
general  condition  did  not  require  treatment  therefor. 

Hemostasis  by  Belt  Constriction.  (Momburg). — As  a  means  of 
checking  hemorrhage  after  severe  trauma,  in  obstetrics,  etc.,  with 
certainty,  without  an  assistant  and  without  the  danger  of  local 
wound  infection,  Momburg  has  sugggested  winding  a  rubber  tube 
tightly  around  the  waist,  one  turn  after  another,  until  the  femoral 
pulse  disappears.  This  procedure,  which  causes  a  sudden  rise  of 
blood-pressure  and  which  throws  a  corresponding  burden  upon  the 
heart,  should  not  be  employed  in  case  of  cardiovascular  disease.^ 
The  suddenness  of  the  cardiac  strain  may  be  somewhat  mitigated 
by  preliminary  constriction  of  the  thighs.  It  is  absolutely  essential 
that  the  constriction  be  very  gradually  relieved  so  that  vasomotor 
tone  and  the  distribution  of  blood  may  be  gradually  reestablished. 
It  should  never  be  applied  in  the  case  of  elderly  or  obese  women. 
Numerous  accidents  have  occurred  from  defective  technic.  This 
procedure  has  not  met  with  any  practical  acceptance,  and  is  by 
many  authorities  condemned  as  a  dangerous  and  unjustifiable 
procedure. 

Abdominal  Conditions. — Blood-pressure  readings  may  be  of  diag- 
nostic value  in  d,bdominal  lesions.  Thus  unilateral  suppurative 
renal  disease  causes  a  rise  of  pressure  which  falls  after  evacuation 
or  extirpation.^  Readings  are  of  value  in  the  diagnosis  in  visceral 
rupture,  ectopic  pregnancy,  gastric  or  intestinal  perforation,  etc., 
all  of  which  conditions  cause  a  sudden  and  often  marked  fall  of 
pressure.  As  a  rule  the  extent  of  the  fall  depends  upon  the  patient, 
the  size  of  the  perforation,  the  coexistence  of  hemorrhage,  the 

'  Spinal  Anesthesia,  Jour.  Am.  Med.  Assn.,  1916,  Ixvi,  1090. 
'  For  detailed  study  see  Adair,  F.  L.:  Surg.,  Gynec.  and  Obst.,  1912,  p.  112. 
'  Kato  and  Kotzenberg:     Ueber  d.  Verhalten  d.  arteriellen  Blutdruckes  bei  chirur- 
gischen  Nierenerkrankungen  u.  Appendicitis,  Beitr.  z.  klin.  Chir.,  1908,  Iviii,  404. 


ABDOMINAL  CONDITIONS  415 

presence  of  localizing  adhesions,  and  the  portion  of  the  peritoneum 
involved.  The  larger  the  perforation,  the  less  it  is  walled  off; 
the  greater  the  associated  hemorrhage  and  the  higher  its  location, 
the  more  will  arterial  pressure  fall.  The  pain  which  often  precedes 
or  is  associated  with  perforation  causes  a  preliminary  rise  of  pressure. 
Pressure  readings  naturally  have  a  much  greater  value  if  the 
patient's  normal  pressure  is  known.  Hence  the  value  of  routine 
pressure  records.  It  is  impossible  to  give  any  rules  based  upon 
absolute  figures,  but  a  systolic  pressure  below  90  mm.  Hg.  in  asso- 
ciation with  other  signs  would  point  to  hemorrhage  or  perforation 
even  in  toxic  patients  prostrated  by  typhoid  fever  (see  page  215). 
Acute  inflammatory  lesions  in  the  peritoneum,  such  as  appendicitis 
in  the  early  stages,  may  cause  a  slight  increase  in  blood-pressure, 
whereas  renal  colic,  plumbic  cramps,  and  tabetic  crisis  generally 
show  a  marked  rise  in  tension.  The  onset  of  peritonitis  is  accom- 
panied by  a  distinct  increase  of  pressure  which  gradually  falls 
with  increasing  toxemia.  The  rise  is  due  to  local  pressor,  the  fall 
to  central  depressor,  impulses. 

The  Application  of  Heat  and  Cold. — Heat  applied  to  the  external 
abdominal  wall  produces  a  rise  of  blood-pressure,  whereas  cold  has 
but  little  if  any,  such  effect.  But  applied  within  the  peritoneal 
cavity,  both  heat  and  cold  produce  a  marked  fall  of  pressure.  This 
is  probably  due  to  stimulation  of  the  splanchnic  nerve.^  The  em- 
ployment of  hot  cloths  or  saline  solution  in  abdominal  operations 
may  therefore  have  deleterious  effects.^ 

The  custom  now  instituted  in  all  up-to-date  clinics  of  having  the 
anesthetist  or  his  assistant  chart  the  pulse  rate  and  blood-pressure 
during  the  course  of  anesthesia,  with  the  addition  of  occasional 
notes  dictated  by  the  operator,  is  most  commendable.  .  It  is  not 
only  a  signal  assistance  to  the  surgeon  at  the  time  of  the  operation, 
but  it  also  leads  to  a  more  careful  analysis  of  the  effects  of  anesthesia 
and  trauma,  and  furnishes  permanent  records  for  statistical  study. 

Practical  Considerations  in  Regard  to  Shock. — Blood-pressure  should 
be  estimated  before,  rather  than  on,  the  day  of  the  operation. 
Certainly  it  should  be  taken  in  the  ward  and  not  in  the  anesthetiz- 
ing room,  otherwise  fallaciously  high  readings  will  be  obtained 
(10  to  20  mm.). 

Shock  is  a  condition  of  gradual,  not  sudden  development.  It 
cannot  be  detected  by  palpating  or  counting  the  pulse  since  a  large 

iRurton-Opitz:    Am.  Jour.  Physiol.,  1916,  xli,  103. 

'  Hammett,  F.  S.,  Tice,  E.  W.,  and  Larson,  E.:  Blood-pressure  Changes  Induced 
by  Hot  and  Cold  Applications  on  and  within  the  Abdomen,  Jour.  Am.  Med.  Assn., 
1917,  Ixviii,  621. 


416      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

pulse-pressure  may  yield  the  impression  of  a  "good  pulse"  even 
when  a  falling  diastolic  pressure  is  already  dangerously  low;  further- 
more, the  pulse  rate  is  not  always  rapid.  Shock  is  to  be  feared, 
however,  if  with  an  increasing  pulse  rate  pressure  remains  stationary, 
or  what  is  worse,  actually  decreases.    Without  a  fall  of  pressure  no 


NoTocaln  9.40 
..(i«S  0.41 

-  Jlelazation  good. 
.  Et.>.llght.^  color  -god. 


R9TO$4ln.. 


Skjlu  Incision  9.42 

Incision... of  muscle - 

Novocain  peritoneum 

Incision  peritoneum 

"•■18;  incision  en-., 

larged  upwards.   No.   .. 

ptosis  or  stomach. 

Palpation  oT  gall-hl.. 
Finney  pyloroplasty...-. 
9.55.-  Ho  tension. 

Finney  completea . 
Incision  enlarged  be- 
low for  colofi. 
Separation  mes. ileum. 
Separation  mes. colon. 


DlTls. mes. completed. 
DiTls. small  intest. 


Colon  out 

Closing  post. peri ton. 


P*  •Tr.end.elen.'burg . 
Pressure  from  115  to 
90.  . 


inastoaosis  begun  11,45 
Subcut.salt  600  .cc^ 


Suctden  cyanoals 
gas  off.i. 


Strophanthln  Img  In  r«l]i« 
Anastom.coTnnlete  12.35 


ft.SUgbtl;  out 
iTendelenburg,  pulse 
weak  and  rapid.... 


Vomiting.  I  brQwpis);  . 

riuM.  -  


"  Closure  perit. begun. 
"Iciosure  perit  .completed. 


Skin  incision  closed  1.00, 


nectal._.9..alt .  .30a.  ee .. 


Fig.  104. — Chart  from  a  case  of  gastromesenteric  ileus,  together  with  pyloric 
stenosis  due  to  a  healed  ulcer,  requiring  a  pyloroplasty  in  addition  to  resection  of  the 
right  half  of  the  colon.  The  operation  lasted  three  hours  and  twenty  minutes.  No 
ether  was  used.  A  marked  fall  of  pressure  occurred  while  closing  the  peritoneum. 
This  was  remedied  by  temporarily  placing  the  patient  in  the  Trendelenburg  position. 
Sudden  cyanosis  with  a  second  fall  of  pressure  occurred  while  the  abdominal  wound 
was  being  closed.  The  nitrous  oxide  was  stopped  and  the  operation  finished  under 
local  anesthesia.  Salt  solution,  strophanthin,  and  the  inverted  posture  again 
restored  the  patient  to  a  satisfactory  condition.     (After  Bloodgood.) 


serious  shock  can  occur.  Variations  of  10  to  15  mm.  are  not  a  cause 
for  apprehension  but  a  continuous  fall  with  a  rising  pulse  rate  is  an 
urgent  indication  for  treatment.  Fall  of  pressure  may  begin  from 
five  to  twenty  minutes  after  the  exciting  cause,  such  as  rough 
handling  of  the  viscera,  traction  on  the  mesentery,  extensive  walling 


MENSTRUATION  417 

off  of  the  viscera  with  gauze  packs,  hemorrhage,  excessive  adminis- 
tration of  the  anesthetic,  etc.  The  sequence  of  events  is  usually 
a  fall  of  diastolic  pressure,  increased  pulse  rate,  decrease  of  pulse- 
pressure,  until  eventually  with  a  diastolic  pressure  of  60  the  pulse- 
pressure  is  only  20  and  the  pulse  rate  over  120.  This  picture 
represents  a  typical  severe  case  of  shock,  to  which  if  it  lasts  half  an 
hour  the  patient  usually  succumbs,  although  life  may  be  prolonged 
for  two  or  three  days  (McKesson). 

Shock  as  a  cause  of  death  stands  relatively  high  in  operations 
immediately  after  accidental  injuries,  in  acute  and  chronic  infectious 
disease,  cachexia,  inanition,  and  in  toxemia  such  as  exophthalmic 
goitre,  auto-intoxication  from  intestinal  obstruction,  trypsin  poison- 
ing in  acute  pancreatitis,  uremia,  diabetic  coma  and  obstructive 
jaundice  (Bloodgood). 

Menstruation. — ^Blood-pressure  frequently  rises  for  a  day  or 
two  preceding  the  onset  of  menstruation.  There  is  a  fall  of  blood- 
pressure  during  the  period  which  occurs  independently  of  the  loss 
of  blood,  and  which  has  been  attributed  to  a  slowing  of  the  pulse 
and  to  psychic  factors.^  It  is  lowest  on  the  second  day  of  the  flow 
and  is  not  much  affected  by  the  occurrence  of  pain  at  this  time.^ 
Large  doses  of  atropin  (0.00075  gm.  hypodermically)  have  some- 
times been  successfully  used  in  the  treatment  of  dysmenorrhea  of 
the  spasmodic  type  associated  with  cramp-like  pain  a  day  or  two 
before  the  onset  of  flow,  especially  in  vagotonic  cases.  Much  stress 
has  been  laid  by  Stolper  upon  the  importance  of  blood-pressure 
estimations  in  the  proper  selection  of  cases.  He  states  that  women 
with  a  normal  or  slightly  increased  pressure  during  the  inter- 
menstrual interval  react  most  promptly  to  atropin,  whereas  those 
with  a  marked  increase  in  blood-pressure  show  less  response. 
Bogdanovics'  and  others  have  reported  a  premenstrual  rise  of  blood- 
pressure  in  normal  women,  followed  by  a  gradual  decline  after  the 
onset  of  flow.  Based  upon  pulse  rate,  blood-pressure,  temperature, 
and  muscular  strength  tests,  the  statement  has  been  made  that  a 
cyclic  rhythm  occurs  in  normal  women  which  renders  them  subject 
to  periodic  intervals  of  inefficiency.'*    The  recent  studies  of  King^ 

1  Wiessner,  M.:  Ueber  das  Verhalten  des  Blutdruckes  wiihrend  der  Menstruation, 
etc.,  Leipsic,  1904. 

2  Tenji,  T.:  Ueber  d.  Verhalten  des  Blutdruckes  zw.  d.  Menstmellen  u.  nieht 
Menstiuellen  Ztschr.,  Arch.  f.  Gynak.,  1909,  Ixxxix,  517. 

3  Zentralbl.  f.  Gynak.,  1910,  xxxiv,  994. 

••  Jacobi:  The  Question  of  Rest  for  Women  during  Menstruation,  Boylston  Prize 
Essay,  1876. 

*  Concerning  the  Periodic  Cardiovascular  and  Temperature  Variations  in  Women, 
Am.  Jour.  Physiol.,  1914,  xxxiv,  203. 
27 


418      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

indicate  that  this  tendency  has  been  overemphasized  and  insofar 
as  observations  are  concerned,  made  upon  the  systolic,  diastoHc 
and  pulse-pressures  of  eleven  women,  such  irregular  results  were 
obtained  that  they  do  not  support  the  wave  theory,  Balard  and 
Sidaine^  were  unable  to  establish  any  constant  relationship  between 
pulse  rate,  blood-pressure  and  menstruation  either  in  different 
women-  or  even  in  the  same  women  at  different  periods. 

The  Menopause. — Circulatory  abnormalities  are  of  frequent 
occurrence  during  the  menopause.  Among  these  "flashes  of  heat," 
formication,  numbness,  vertigo,  cardiac  palpitation,  dyspnea  on 
exertion,  etc.,  may  be  encountered.  A  rise  of  arterial  pressure  is 
not  uncommon  after  the  cessation  of  menstruation.  Whether  it  is 
merely  a  symptom  or,  as  Potter^  suggests,  the  cause  of  the  symptoms, 
is  uncertain.  The  diastolic  does  not  increase  proportionately  with 
the  systolic  pressure.  Pulse-pressure  is  thus  increased.  Further- 
more, the  increased  pressure  is  an  irregular  and  intermittent  one. 
In  some  cases  hypotension  with  systolic-diastolic  deviation  occurs. 
Culbertson*  states  that  the  administration  of  extract  of  corpus 
luteum  brings  about  a  gradual  restoration  of  blood-pressure  to- 
gether with  the  disappearance  of  mental  symptoms.  If  pressure 
changes  are  marked  and  prolonged  the  possibility  of  renal  disease 
must  be  borne  in  mind.  Engelhorn^  has  reported  a  marked  allevia- 
tion of  symptoms  such  as  "hot  flashes"  as  a  result  of  phlebotomy. 

Ovarian  extirpation  clinically  often  produces  evidences  of  increased 
irritability  of  the  sympathetic  nervous  system.  This  has  been 
substantiated  experimentally,  since  this  operation  in  bitches  results 
in  from  six  to  eight  weeks  in  a  markedly  increased  vasomotor 
reaction  after  one  injection  of  nicotin.  The  reaction  to  epinephrin, 
however,  is  not  increased.^  Jaschke"  considers  increased  blood- 
pressure  the  most  pronounced  result  of  cessation  of  ovarian  secre- 
tion and  explains  its  absence  when  not  present  as  a  result  of  vicarious 
function  of  other  endocrine  glands.  But  Dubois  and  Waltham  did 
not  corroborate  Jaschke's  findings.  They  failed  to  get  either  hyper- 
tension or  adrenalin  glycosuria  when  the  climacteric  had  been 
artificially  induced. 

>  Arch.  Mens.  d'Obstet.,  January-March,  1916,  v. 

'  Blood-pressure  at  the  Climacteric,  British  Med.  Jour.,  December  2,  1911,  p.  1472. 
'  Study  of  the  Menopause  with  Special  Reference  to  Vasomotor  Disturbances, 
Surg.,  Gynec.  and  Obst.,  1916,  xxiii,  667. 

*  Miinchen.  med.  Wchnschr.,  1915,  Ixii,  No.  45. 

'  Hoskins  and  Wheelon :  Ovarian  Extirpation  and  Vasomotor  Irritability,  Am. 
Jour.  Physiol,  1914,  xxxv,  119. 

•  Miinchen.  med.  Wchnschr.,  November  9,  1915. 


PREGNANCY  419 

Extirpation  of  the  testes  is  followed  by  a  fall  of  blood-pressure, 
and  the  reaction  to  nicotin  is  constantly  lowered.^  The  presence  of 
successful  testicular  grafts  in  any  portion  of  the  body  reestablishes 
the  normal  vasomotor  response.^  It  would  seem,  therefore,  that 
normally  functionating  testes  bear  a  relationship  to  irritability  of 
the  sympathetic. 

Pregnancy. — Systolic  blood-pressure  ranges  between  100  and  130 
in  about  80  per  cent,  of  pregnant  women.  In  about  10  per  cent, 
pressure  will  be  found  below  100  mm.  It  has  been  stated^  that 
cases  with  pressures  of  less  than  90  mm.  are  apt  to  exhibit  signs  of 
shock  at  the  time  of  delivery,  but  Irving^  did  not  corroborate  this. 
The  remaining  10  per  cent,  of  cases  will  show  a  pressure  of  130  or 
more. 

The  importance  of  blood-pressure  observations  in  pregnancy  is 
universally  recognized  since  hypertension  is  a  more  unportant  and 
reliable  index  of  toxemia  than  is  albuminuria.  This  statement  applies 
both  qualitatively  and  quantitatively.  Subsidence  of  the  uterus 
-may  be  associated  with  a  slight  fall  in  pressure.  The  normal  rela- 
tions between  systolic  and  diastolic  pressure  should  remain  constant. 
Cases  showing  a  pulse-pressure  of  or  over  50  mm.  should  be  watched 
and  are  benefited  by  digitalis.^  Edema  in  pregnancy  bears  no 
constant  relation  to  blood-pressure.^ 

What  was  previously  described  as  the  normal  cardiac  hyper- 
trophy in  pregnancy  is  really  only  a  change  in  the  lateral  percussion 
area,  due  to  the  more  transverse  position  of  the  heart  which  the 
upward  pressure  upon  the  diaphragm  entails  (Stengel  and  Stanton). 
This  transverse  position  tends  to  cause  a  kinking  of  the  large 
vessels,  which  adds  to  the  work  expended  by  the  heart,  and  in  the 
case  of  a  diseased  myocardium  this  factor  may  become  important. 
It  also  explains  the  occurrence  of  accidental  pulmonary  murmurs. 

The  normal  blood-pressure  during  the  second  stage  of  labor,  if 
taken  between  uterine  contractions,  ranges  between  130  and  150 
mm.  After  delivery  normal  values  are  reestablished.  This  fall 
is  due  to  fatigue,  cessation  of  excitement,  and  pain,  as  well  as  to 

1  Wheelon,  H.:     Influence  of  Testes  on  Blood-pressure,  Am.  Jour.  Physiol.,  1914, 

XXXV. 

2  Wheelon,  Homer  and  Shipley:  The  Effects  of  Testicular  Transplants  upon 
Vasomotor  Irritability,  Am.  Jour.  Physiol.,  1916,  xxxix,  394. 

'  Lynch:    Surg.,  Gynec.  and  Obst.,  1913,  xvii,  472. 

*  The  Systolic  Blood-pressure  in  Pregnancy,  .lour.  Am.  Med.  Assn.,  1916,  Ixvi,  935. 
(An  excellent  article  based  upon  a  study  of  5000  cases  to  which  I  am  indebted  for 
much  information.) 

^  Hirst,  J.  C:  Blood-prcssurc  in  Pregnancy,  Penn.  Med.  Jour.,  May,  1915,  p.  615. 

8  Rosensohn,  M.:  Parallel  Study  of  Blood-pre.s.sure,  Urine  and  P'.dema  in  Preg- 
nancy, Bull.  Ljdng-In  Charity,  Citj'  of  New  York,  January,  1917. 


420      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

vascular  relaxation  in  the  splanchnic  domain.  During  the  jMin^s 
pressure  estimations  cannot  well  be  made,  but  doubtless  the  pain 
as  well  as  the  abdominal  compression  cause  much  higher  blood- 
pressure.  Rvphire  of  the  memhrmies  usually  produces  a  marked  but 
temporary  fall  in  pressure.  The  hirth  of  the  child  is  again  followed 
for  a  time  by  a  fall  of  from  60  to  90  mm.^  These  changes  in  blood- 
pressure  are  due  to  the  sudden  diminution  of  intra-abdominal 
tension,  to  which  it  takes  some  time  for  the  vasomotor  system  to 
accommodate  itself.  Large  hemorrhages  tend  to  delay  the  return 
of  pressure  to  the  normal. 


Elevated  Blood-pressure,  Albuminuria  and  Toxemia  According 
TO  Age.     (Irving.) 

Number  of 
Age.  cases. 

Under  20 421 

20  to  30 3165 

30  to  40 1283 

Over  40 131 


Elevated 

blood-pressure. 

Albuminuria. 

Toxemia. 

11.4 

20.0 

2.8 

8.9 

13.7 

1.0 

14.3 

12.2 

1.5 

22.1 

17.5 

1.5 

Although  increased  pressure  is  more  common  in  elderly  gravidas, 
it  is  in  such  cases  less  important  as  an  evidence  of  toxemia  than 
in  younger  women.  Hypertension  unaccompanied  by  albuminuria 
or  other  evidences  of  toxemia  is  not  unusual  and  often  responds 
to  free  purging.  "A  progressively  rising  blood-pressure,  often 
from  a  low  level,  even  though  it  never  reaches  the  arbitrary  danger 
point,  should  be  regarded  with  apprehension  as  a  most  valuable 
sign  of  approaching  toxemia"  (Irving). 

It  is  of  course  important  to  know  what  a  woman's  normal  pressure 
range  is  before  drawing  conclusions,  but  as  a  general  rule  eclampsia 
does  not  occur  with  a  pressure  below  150.  When  eclampsia  does 
occur,  pressures  in  the  neighborhood  of  200  mm.  are  usual  and 
generally  associated  with  albuminuria. 


Elevated  Blood-pressure,  Albuminuria  and  Toxemia  According 


Parity. 
Prjmparas  . 
Secundiparas 
Tertiparas  . 
Quartiparas 
Quintiparas 
Sextiparas  . 
Septiparas  . 


TO  Parity. 

(Irving.) 

Number  of 
cases. 

Elevated 
blood-pressure 

Albuminuria. 

Toxemia. 

1679 

12.2 

14.8 

1.1 

1036 

7.5 

11.7 

0.8 

696 

7.9 

11.8 

1.0 

508 

11.8 

14.6 

1.4 

360 

8.9 

10.6 

0.6 

261 

10.7 

9.2 

0.8 

177 

13.8 

11.4 

0.6 

1  Heynemann,  Th. :   Herz  u.  Zwerchfellstand  wahrend  Schwangerschaft,  Ztschr.  f . 
Geburtsh.  u.  Gynak.,  1913,  Ixxiv,  854. 


TREATMENT  OF  ECLAMPSIA  421 

A  rising  pressure  during  the  latter  part  of  pregnancy  is  the  most 
constant  symptom  of  gestational  toxemia  and  is  a  frequent  pre- 
cursor of  eclampsia  (Hirst). ^  The  hypertension  increases  with  the 
severity  of  the  attack.  Many  of  Edgar's  cases  showed  pressures  of 
200  mm.  or  more.  "A  fall  of  blood-pressure  with  amelioration  of 
the  other  symptoms  is  the  most  favorable  prognostic  sign,  but 
with  aggravation  of  other  symptoms  indicates  impending  death." 
Intermissions  with  lowered  pressure  are  favorable  omens.  The 
other  symptoms  are  generally  an  increased  pulse  rate,  epigastric 
pain,  headache,  visual  disturbances,  edema,  albuminuria.  Cases 
with  renal ,  disease  rarely  pass  through  the  period  of  gestation 
without  some  manifestations  of  toxemia.  The  absence  of  increased 
blood-pressure  does  not  always  exclude  the  possibility  of  eclampsia ; 
the  presence  of  high  pressure  between  convulsions  does  exclude 
epilepsy  (Chirie). 

In  the  early  stages  of  toxemia,  gastro-intestinal  symptoms  may 
be  marked  before  blood-pressure  changes  are  obvious,  and  fatal 
convulsions  may  not  be  attended  by  a  pressure  over  160  mm. 
Hirst  has  reported  a  reading  of  320  mm.  in  eclampsia  and  192  mm. 
in  a  case  of  toxemia  without  eclampsia.  He  has  seen  recovery  in 
two  cases  with  pressures  of  420  and  400  mm.  respectively,  showing 
that  the  danger  of  death  is  not  necessarily  proportionate  to  the 
height  of  pressure.  The  average  eclampsia  pressure  ranges  between 
190  and  200  mm. 

The  administration  of  ergot  does  not  appear  to  raise  blood- 
pressure  in  the  toxemia  of  pregnancy  (see  page  344),  but  the  employ- 
ment of  pituitrin  may  cause  a  very  marked  rise  (Hirst). 

Summary. — During  pregnancy  a  pressure  of  125  mm.  is  normal; 
a  pressure  between  125  and  150  is  to  be  regarded  with  suspicion; 
while  a  pressure  of  over  150  if  accompanied  by  other  toxemic 
symptoms  calls  for  prompt  and  energetic  treatment;  often  the 
induction  of  premature  labor  (J.  C.  Hirst). 

The  Treatment  of  Eclampsia. — Some  obstetricians  of  wide  ex- 
perience recommended  the  use  of  veratrum  viride  in  the  treatment 
of  eclampsia.  Hirst  states  that  "the  most  successful  remedial 
measures  are  those  which  reduce  blood-pressure  most  quickly  and 
most  effectually,  such  as  puncture  of  the  membranes,  sweating, 
purgation,  venesection,  veratrum  viride,  and  nitroglycerin,"  while 
Edgar  writes:  "I  prefer  ether,  veratrum  viride,  glonoin,  and  chloral 
in  the  order  named."    Now  clinical  results  are  of  primary  impor- 

1  The  Importance  of  Blood-pressure  in  the  Toxemia  flf  the  Latter  Half  of  Preg- 
nancy, New  York  Med.  Jour.,  1910,  xci,  1204. 


422      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

tance,  but  in  view  of  some  definitely  established  facts  it  would 
appear  that  they  are  open  to  revision.  We  have  seen  under  the 
discussion  of  nephritis  that  hypertension  often  appears  to  be 
Nature's  defense  against  anuria  and  coma,  and  the  most  experi- 
enced clinicians  no  longer  attempt  to  reduce  blood-pressure  by 
direct  means  except  in  cases  of  an  emergency.  Is  eclampsia  such 
an  emergency?  The  reduction  of  pressure  allays  the  convulsions, 
but  is  this  due  to  the  fact  that  the  patient  is  too  depressed  to 
respond  to  stimuli?  It  has  been  established  that  collapse  and 
shock  are  associated  with  and  are  in  part  the  result  of  low  blood- 
pressure.  By  administering  cardiovascular  depressants  are  we 
not  reducing  our  eclamptic  patient  to  a  condition  of  collapse?  It 
has  been  shown  that  rapid  emptying  of  the  uterus  in  eclampsia 
frequently  produces  a  fall  of  blood-pressure  amounting  to  100  mm. 
Hg.,  while  a  full  dose  of  veratrum  viride  of  itself  may  cause  a 
depression  of  145  mm.^  It  is  unpleasant  to  contemplate  the  degree 
of  blood-pressure  fall  which  a  combination  of  these  two  procedures 
might  entail.  Even  if  the  eclamptic  rise  of  pressure  is  not  of  a 
protective  nature,  and  even  if  it  should  appear  desirable  to  lower 
pressure  by  medicinal  means  it  would  seem  far  preferable  to  do 
so  by  the  administration  of  the  nitrites — drugs  which  do  not  also 
depress  the  heart  and  the  medullary  centres.  Chloroform  is 
undesirable  not  only  because  of  its  effect  upon  the  heart,  but  also 
on  account  of  its  tendency  to  produce  necrosis  of  the  hepatic  cells. 
Eclampsia  is  more  than  a  vascular  crisis,  and  while  much  higher 
blood-pressure  favors  and  doubtless  precipitates  visceral  hemor- 
rhages, such  a  rise  of  tension  is  only  a  symptom  and  not  the  basis 
of  gestational  intoxication.  So  far  as  the  writer  is  aware,  blood- 
pressure  readings  yield  no  clue  as  to  the  relative  indication  for 
immediate  Cesarean  section  or  conservative  treatment. 

Hyperemesis  gravidarum  is  usually  associated  with  hypotension 
perhaps  as  a  result  of  impoverished  nutrition,^  and  indicating  that 
the. toxin  is  different  from  that  causing  eclampsia. 

In  extra-uterine  'pregnancy  the  occurrence  of  anemia  with  a  fall 
of  pressure  is  the  most  important  indication  of  internal  hemorrhage 
(Horner). 

Attention  has  been  called  to  the  fact  that  shock  associated  with 
and  probably  due  to  low  blood-pressure  may,  even  in  the  absence 
of  large  hemorrhages,   lead  to  sudden  death  during  childbirth. 

1  Bailey,  A.  C:   Shock  in  Eclampsia,  Am.  Jour.  Obst.,  1911,  Ixiv,  No.  2. 
*  WalJieh,  V.:     L' hypertension  gravidique,  Ann.  d.  Gynec.  et  d'Obst.,  1912,  xxxix, 
653. 


BLOOD-PRESSURE  OBSERVATIONS  DURING  ANESTHESIA     423 

Women  with  pressures  not  exceeding  90  mm.  may  pass  through 
labor  normally,  but  such  low  readings,  especially  if  associated 
with  anemia,  always  indicate  special  care  and  the  institution  of 
such  measures  as  tend  to  prevent  shock.  ^  Poorly  developed, 
neurasthenic  women  or  women  with  contracted  pelves  often  have 
low  pressures. 

Fibromyomata  of  the  Uterus. — There  is  no  definite  relationship 
between  uterine  fibromyomata  and  blood-pressure.  In  148  cases 
studied^  the  height  of  the  pressure  seemed  entirely  independent 
of  the  size  or  character  of  the  tumors  before  operation.  After 
operation  3  cases  showed  an  unchanged  pressure,  11  an  increase 
of  from  5  to  65  mm.,  and  8  a  decrease  of  from  5  to  40  mm.  Hg. 


Fig.  105. — McKesson's  sphygmomanometer  for  use  during  operations.     (Gwathmey.) 

Scopolamin-morphin. — The  employment  of  scopolamin-morphin 
analgesia  in  labor  has  little  or  no  effect  upon  blood-pressure. 
Baer's^  cases  showed  an  average  drop  of  5  mm. 

Blood-pressure  Observations  during  Anesthesia. — With  the 
intention  of  rendering  blood-pressure  readings  much  easier  during 
anesthesia,  Nicholson  has  fitted  his  new  pocket  sphygmoman- 
ometer with  a  Fedde  indicator,  in  which  a  pith-ball  plays  up  and 


1  Lynch,  F.  W.:  Blood-pressure  during  Pregnancy,  Surg.,  Gynec.  and  Obst., 
1913,   xvii,   472. 

*  Taylor  and  White:  Blood-pressure  in  Fibromyomata  Uteri,  Surg.,  Gynec.  and 
Obst.,  1916,  xxii,  216. 

'  Scopolamin-morphin  Treatment  of  Labor,  Jour.  Am.  Med.  Assn.,  1915.  Ixiv.  1723. 


424      BLOOD-PRESSURE  IN  SURGERY  AND  OBSTETRICS 

clown  as  long  as  pulsations  of  pressure  are  transmitted  to  it.  This 
is  attached  to  the  left-hand  side  of  the  box  and  connected  up  with 
the  manometer  and  two  cuffs,  one  above  and  one  below  the  elbow 
or  knee-joints. 

An  air-pressure  of  about  80  mm.  may  be  maintained  in  the  lower 
cuff  throughout  the  operation,  and  the  character,  volume,  and  rate 
of  the  pulse  noted  continuously.  The  anesthetizer  inflates  the  upper 
cuft'  with  one  hand  whenever  he  desires  to  know  the  systolic  pressure, 
simply  noting  the  height  of  the  mercury  column  when  the  pith- 
ball  ceases  oscillating.  He  then  releases  the  air-pressure  in  the 
upper  cufl"  and  continues  the  anesthesia.  In  perineal  operations 
the  cuffs  are  placed  on  the  arm  and  forearm  instead  of  the  thigh 
and  leg. 


CHAPTER  XVIII. 


OPHTHALMOLOGY. 


Since  the  ophthalmoscope  is  the  only  instrument  which  renders 
the  naked  arteries  and  veins  visible  during  life  it  is  not  surprising 
that  important  data  regarding  blood-pressure  or  stasis,  or  vascular 
degeneration  should  be  forthcoming  from  this  source.  The  char- 
acteristic retinal  lesions  due  to  arteriosclerosis  and  arterial  hyper- 
tension, are  not  infrequently  discovered  by  the  ophthalmologist 
before  other  s\Tnptoms  cause  the  patient  to  consult  his  physician. 
Ophthalmoscopic  examinations  are  of  value  to  the  student  of 
blood-pressure  no  less  than  are  sphygmomanometric  estimations 
to  the  ophthalmologist. 


Fig.  106. — Rubino's  modification  of  the  Bloch-Verdin  Sphygmometer, 


Blood-pressure  in  the  Retinal  Arteries. — The  maximal  pressure 
in  healthy  retinal  arteries  ranges  between  80  and  112  mm.  Hg., 
according  to  Rubino,  who  has  modified  the  Bloch-Verdin  apparatus 
for  its  measurement.  The  determination  is  based  upon  the  principle 
that  a  certain  pressure  exerted  upon  the  eyeball  will  arrest  the 
circulation,  this  being  indicated  by  the  temporary  loss  of  sight  in 
the  eye  in  question  (Fig.  107). 

The  Relation  of  Blood-pressure  to  Ocular  Tension. — For  practical 
purposes  the  eye  may  be  regarded  as  an  inelastic  capsule,  having  a 
tension  greater  than  the  atmosphere,  which  varies  as  the  intra- 
ocular contents  are  increased  or  decreased.  Such  changes  are 
brought  about  mainly  by  alterations  in  the  blood  supply,  the 
vitreous  or  the  aqueous.     "The  circulatory  conditions  in  the  eye 


426 


OPHTHALMOLOGY 


resemble  those  in  the  intracranial  cavity,  with  the  exception  that 
the  intra-ocular  is  much  higher  than  the  intracranial  pressure, 
and  is  therefore  not  affected  by  changes  in  the  general  venous 
pressure"  (Hill  and  Flack^).    Intra-ocular  tension  generally  varies 


Fig.  107. — The  Rubino  instrument  in  use. 


Fig.  108. — The  Bajardi  instrument  for  estimating  retinal  arterial  pressure.* 

with  arterial  pressure,  but  peripheral  vasodilatation  which  lowers 
systemic  pressure  tends  to  increase  intra-ocular  pressure.  Normally 
any  change  of  tension  is  compensated  by  a  reciprocal  lymphatic 


>  I.  The  Relation  between  Capillary  Pressure  and  Secretion.  II.  The  Secretion 
of  Aqueous  and  the  Intra-ocular  Pressure,  Proc.  Roy.  Soc,  Series  B,  August  12, 
1912,  XXV. 

'  La  Pressione  del  sangue  nell'  arteria  retinica  e  suoi  rapporti  con  la  pressione  nel 
cercolo  del  Willis,  Riforma  Med.,  1911,  xxvii,  1345. 


RELATION  OF  BLOOD-PRESSURE  TO  OCULAR  TENSION     427 

flow.  Excluding  external  causes  (eyelids,  ocular  muscles,  tumors  of 
the  eyeball  or  orbit),  changes  in  tension  mean  loss  of  secretory 
compensation,  which  may  come  about  "either  by  mechanically 
blocking  the  normal  excretory  channels  or  by  so  altering  the  normal 
ciliary  secretion  as  to  interfere  with  its  ready  interchange" — the 
"secretion"  of  the  ciliary  body  is  not  truly  a  secretion  in  the  physi- 
ological sense  of  the  term,  but  an  osmotic  process,  the  passage  of 
fluid  through  a  dialyzing  membrane.  There  are  no  lymphatics 
in  the  eye,  and  the  iris  and  vitreous  have  no  secretory  function." 
According  to  Starling  and  Henderson  the  difference  between  arterial 
and  intra-ocular  tension  averages  84  mm.,  and  it  is  upon  these 
pressure  differences  that  the  rate  of  secretion  depends.  The  specific 
gravity  of  the  secretion  varies  directly  with  blood-pressure  and 
inversely  with  ocular  tension.  "Permanently  increased  tension 
is  not  due  to  high  blood-pressure  directly,  but  may  coexist  with 
it  only  in  the  absence  of  adequate  compensation"  (Ibershoff) 
(see  page  46). 

The  foregoing  statements  are  generally  accepted.  In  opposition 
to  them  Henderson  believes  that  intra-ocular  and  intracranial 
tension  run  closely  parallel.  The  latter  depends  much  more  upon 
the  general  venous  than  upon  the  general  arterial  pressure.  It 
varies  directly  and  absolutely  with  the  pressure  in  the  vena  cava, 
which  makes  itself  felt  at  once  by  backward  pressure  on  the  cerebral 
venous  capillaries.  A  rise  of  arterial  pressure  only  produces  a 
proportional  rise  in  the  intracranial  pressure,  because  between 
the  aorta  and  the  cerebral  veins  lies  the  unknown  and  varj'ing 
resistance  of  the  arterioles. 

Based  upon  experimental  evidence,  Henderson  believes  that 
what  has  just  been  stated  regarding  intracranial  tension  applies 
to  intra-ocular  pressure,  except  that  response  in  the  latter  is  less 
prompt  owing  to  the  ramifications  of  the  ocular  veins.  Therefore 
"  the  intra-ocular  pressure  must  be  the  same  as  the  intra-ocidar  venous 
pressure."  Since  the  corneoscleral  envelope  is  an  unyielding  case 
with  a  fixed  cubic  capacity,  analogous  in  every  respect  to  the  bony 
cranium,  the  intra-ocular  pressure  is  not  a  question  of  volume  of 
the  intra-ocular  contents  but  purely  a  question  of  pressure  of  a 
fixed  volume,  which  is  governed  in  turn  by  the  intra-ocular  and 
general  venous  pressure.  The  intra-ocular  pressure  therefore 
represents  "the  pressure  which  remains  in  the  eyeball  after  the 
force  of  the  heart  has  been  expended  in  driving  the  blood  through 
the  intra-ocular  arterioles.  On  account  of  the  elastic  nature  of  the 
circulatory  system  of  tubes  a  rise  of  arterial  pressure  can  onh' 


428 


OPHTHALMOLOGY 


produce  an  increase  in  intra-ocular  pressure  in  proportion  as  the 
resistance  in  the  arterioles  is  overcome  and  intravenous  pressure 
raised."^ 

The  Estimation  of  Intra-ocular  Tension.— The  old  method  of 
gauging  ocular  tension,  which  for  practical  purposes  may  be  con- 
sidered synonymous  with  intra-ocular  pressure,  by  means  of  the 
fingers,  is  for  obvious  reasons  falling  into  disuse  when  anything 
like  accurate  measurement  is  desired.  The  tadns  ervditus  cannot 
compete  with  instrumental  precision.  Sev- 
eral instruments  are  now  available  for  the 
purpose.  Among  these  the  Schiolz  tonometer 
has  received  widespread  commendation  (see 
Fig.  109). 

Intra-ocular  tension  is  rated  with  this 
instrument  by  measuring  the  depth  of  the 
depression  produced  in  the  anesthetized 
cornea  b}^  the  weight  of  the  shaft  of  the 
tonometer;  the  higher  the  tension  the  less 
the  depression.  The  data  obtained  are, 
however,  based  upon  (1)  the  elasticity  of 
the  sclera  and  cornea,  (2)  the  intra-ocular 
tension,  and  (3)  the  condition  of  the  ocular 
drainage  system.^  Normal  readings  should 
not  exceed  26  mm.  Hg. ;  the  normal  pressure 
is  about  20  mm. 

As  with  other  ocular  tonometers,  consider- 
able practice  is  required  before  accurate 
readings  can  be  obtained.  Even  with  careful 
application  considerable  discomfort  to  the 
patient  is  entailed.  No  pressure  should  be 
made  upon  the  eyeball  except  that  exerted 
by  the  weights. 
The  Stephenson  tonometer  is  applied  over  the  closed  upper  lid. 
It  is  furnished  with  a  handle  for  holding  it  in  position  on  the  patient's 
face  and  with  a  milled  head  for  adjustment  to  varying  depths. 
The  end  of  the  inner  tube,  which  consists  of  a  concave  cup,  contains 
a  spiral  spring  actuated  by  a  jointed  lever.  The  instrument  is 
adjusted  to  zero,  the  lever  makes  pressure  upon  the  eye,  and  the 
moment  at  which  indentation  occurs  is  shown  on  the  indicator. 


Fig.   109.— The  Schiotz 
tonometer. 


*  Henderson,  T.:    Glaucoma,  London,  1910. 

2  Schonberg,   M.  J.:     Experimental  Study  of  Intra-ocular  Pressure  and  Ocular 
Drainage,   Jour.   Am.   Med.   Assn.,    1913,  Ixi,    1098. 


OCULAR  LESIONS  AND  ARTERIAL  PRESSURE  429 

Since  the  tension  of  the  orbicularis  palpebrarum  and  the  lecession 
of  the  eyeball  into  the  orbit  are  fairly  constant  in  a  given  individual, 
temporal  variations  of  pressure  can  be  estimated.  The  technic 
with  this  instrument  is  easily  acquired.  No  anesthetic  is  necessary 
and  readings  may  be  made  in  about  one  minute.  Just  what  pro- 
portion of  the  pressure  obtained  is  true  intra-ocular  tension  and 
how  much  is  pressure  of  the  retrobulbar  tissues  is  as  yet  not  posi- 
tively determined.^ 

Ocular  Lesions  due  to  Increased  Arterial  Pressure. — This  subject 
cannot  of  course  be  discussed  here  in  extenso.  "  In  the  later  stages 
of  intra-ocular  vascular  disease,  hemorrhages  frequently  appear. 
If  centrally  placed,  their  very  position  interferes  with  vision,  or 
they  may  invade  the  vitreous,  may  result  in  proliferating  retinitis, 
may  cause  glaucoma,  and,  if  extensive,  detachment  of  the  retina. 
Closely  allied  to  vascular  changes  are  also  lenticular  cataract,  some 
varieties  of  optic  atrophy,  and  some  cases  of  retrobulbar  neuritis" 
(de  Schweinitz).  According  to  William  F.  Norris,  retinitis  in  some 
form  occurs  in  not  less  than  25  per  cent,  of  all  cases  of  Bright's 
disease  seen  in  general  hospitals. 

In  a  study  of  104  cases  of  ocular  disease,  Peter^  found  blood- 
pressure  as  follows: 

9  syphilitic  neuroretinitis,  average  systolic  blood-pressure  .      .  132  mm. 
3  chronic   parenchymatous  nephritis,   average   systolic   blood- 
pressure    132  " 

20  retinitis,  average  systolic  blood-pressure 165  " 

59  neuioretinitis,  average  systolic  blood-{)ressure        ....  185  " 

3  albuminuric  retinitis,  average  systolic  blood-pressure        .      .  190  " 

6  hemorrhagic  retinitis,  average  systolic  blood-pressure       .      .  205  " 

3  papillitis,  average  systolic  blood-pressure 225  " 

Slocum  has  submitted  statistics  which  indicate  that  many  of 
the  serious  fundus  lesions  of  nephritis  are  dependent  at  least  in 
part  upon  some  other  factor  than  the  angiosclerosis.  Similar 
lesions  occur  in  cases  showing  but  little  increase  in  blood-pressure. 

Lenticular  Cataract. — What  has  already  been  said  regarding  the 
effect  of  arterial  hypertension  in  altering  the  osmotic  balance  of 
the  ocular  fluids  may  in  a  measure  apply  to  lenticular  cataract, 
if  we  assume  that  clouding  of  the  lens  is  due  to  an  abnormal  dialysis 
between  the  anterior  and  the  posterior  chambers  of  this  structure. 

'  Reber,  W.;  A  Clinical  Study  of  Ociilar  Tonometers,  Penn.  Med.  Jour.,  1913, 
xvii,  281. 

2  Peter,  L.  C:  Arterial  Hypertension  and  its  Relation  to  Morbid  Changes  in  the 
Eye,  Penn.  Med.  Joxir.,  1911,  xiv,  411. 


430 


OPHTHALMOLOGY 


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' 

Total  cases 

Male 

Female 

Edema  of  the  disk,  retina  or 
macula 

Congestion  or  slight  swelling 
of  the  disk     .      .      ... 

Swelling  of  disk  1  D.  or  more 

Periarteritis 

Endarteritis 

tracted  arteries  .... 
Silver  wire  arteries 
Corkscrew  vessels 
Arteriovenous       compression 

with  or  without  dilatation 
Veins,  irregular,  engorged  or 

tortuous  

Periphlebitis     .... 
Venous  thrombosis 

Hemorrhages 

Exudates   and   other    retina 

changes   

Radiating  or  star-shaped  mac 

ular  changes        ... 
Other  macular  changes     . 
Choroidal  changes 
Aneurysmal  dilations  and  var 

icosities 

Inflammatory    characteristic 

OCULAR  LESIONS  AND  ARTERIAL  PRESSURE 


431 


Fig.  110. — Graphic  representation  of  totals  and  percentages  in  the  Table,  p.  430. 
Each  group  represents  the  percentages  of  the  features  as  they  would  appear  in  an  equal 
number  of  cases:  M,  male;  F,  female;  1,  edema  of  disk,  retina  or  macula;  2,  conges- 
tion or  slight  swelling  of  the  disk;  3,  swelling  of  disk  1  D,  or  more;  4,  peri-arteritis; 
5,  endarteritis;  6,  irregular  tortuous  arteries;  7,  silver- wire  arteries;  8,  cork-screw 
vessels;  9,  arteriovenous  compression;  10,  engorged  tortuous  veins;  11,  periphlebitis; 
12,  venous  thrombosis;  13,  hemorrhages;  14-,  exudates,  etc.,  retina;  15,  retinal  detach- 
ments; 16,  radiating  macular  changes;  17,  other  macular  changes;  18,  choroidal 
changes:  19,  aneurysmal  changes. 

Glaucoma. — The  general  consensus  of  opinion  appears  to  be  that 
arterial  hypertension  bears  only  an  indirect  relation  to  glaucoma. 
This  condition,  which  is  predisposed  to  by  a  large  lens  and  a  small 
cornea,  may  be  precipitated  by  a  congestion  or  hemorrhage  in  the 
ciliary  region  which  interferes  with  the  compensating  mechanism. 
"In  the  former  the  heightened  blood-pressure  causes  increased 
secretion  which  in  the  presence  of  altered  arterial  walls  is  of  a 
higher  specific  gravity  than  normal,  so  that  the  already  impaired 
drainage  is  further  embarrassed  and  compensation  fails.  In  the 
case  of  hemorrhage,  the  lymph  mixed  with  blood  clogs  the  outflow 
channels  and  failure  of  excretion  follows"  (Ibershoff).  If  the 
foregoing  facts  are  accepted,  operative  measures  should  not  be 
attempted  without  first  lowering  arterial  pressure,  since  the  opening 
of  the  anterior  chamber  or  of  the  sclera  would  be  followed  by 
"the  rapid  reformation  of  ocular  fluids  of  a  much  higher  specific 
gravity  and  osmotic  coefficient."  The  danger  of  expulsive  hemor- 
rhage would  also  be  diminished  if  systemic  pressure  were  lowered. 
Craggs  and  Taylor,  from  several  hundred  comparisons,  were  unable 
to  establish  any  relations  between  glaucoma  and  increased  arterial 
tension.^  McRae's^  studies  of  20  cases  lead  him  to  draw  similar 
conclusions. 

*  Craggs,  H.  C,  and  Taylor,  C.  G.:     A  Research  into  the  Relation  between  Sys- 
temic Blood-pressure  and  Raised  Intra-ocular  Tension,  Ophthalmoscope,  1913,  xi,  350. 
2  Ophthalmoscope,  April,  1915,  p.  168. 


432  OPHTHALMOLOGY 

Lohlein,'  who  studied  some  twenty  cases  of  glaucoma  by  com- 
paring the  general  blood-pressure,  the  intra-ocular  pressure,  and 
the  adrenalin  content  of  the  blood,  was  unable  to  corroborate 
Kleczkowski's  statement  that  a  definite  relationship  existed.  It  is 
generally  conceded,  however,  that  no  study  of  either  acute  or 
chronic  glaucoma  is  complete  without  a  record  of  the  systemic 
arterial  tension. 

The  belief  that  prunary  glaucoma  is  the  product  of  retention 
of  intra-ocular  volume  has  been  widely  accepted.  In  opposition 
to  this  hypothesis,  Thomas  Henderson  offers  a  different  explanation. 
Every  case  of  primary  glaucoma  depends  upon  (1)  a  constant 
predisposing  sclerotic  factor,  and  (2)  on  the  variable  vascular  factor 
which  is  directly  due  to  the  general  circulatory  pressure.  Since 
neither  the  eye  nor  the  brain  possesses  any  protective  circulatory 
mechanism,  "  a  rise  in  the  vena  cava  pressure  produces,  millimeter 
for  millimeter,  a  corresponding  and  equal  rise  in  intra-ocular  and 
intracranial  pressures,  while  increase  of  pressure  in  the  aorta  causes 
a  rise  of  pressure  in  the  eye  and  brain  whose  exact  amount  depends 
on  the  varying  resistance  of  the  arterioles.  Glaucoma  therefore 
may  be  caused  by  a  rise  of  arterial  pressure,  but  is  specially  to  be 
feared  when  there  is  a  rise  of  the  general  venous  pressure.  This 
in  an  eye  with  a  sclerotic  cribriform  ligament,  and  therefore  a 
diminished  access  of  aqueous  to  the  veins,  precipitates  the 
attack.2 

Retinal  Hemorrhages. — Retinal  hemorrhages  often  show  a  more 
or  less  direct  relation  to  increase  of  vascular  tension,  and  ocular 
changes  are  most  commonly  noted  in  severe  cases  of  nephritis  at 
the  time  at  which  the  pressure  is  highest.  Thus  hemorrhages  into 
the  retina  are  often  precipitated  by,  and  directly  attributable  to 
conditions  which  suddenly  raise  the  intracranial  arterial  pressure, 
such  as  lifting,  stooping,  straining,  etc. 

The  presence  of  retinal  hemorrhages  in  a  case  of  chronic  arterial 
hypertension  point  almost  indubitably  to  a  severe  nejjhritis. 
.Retinal  changes  in  nephritis  have  been  re])orted  as  follows:  Wagner 
'in  6  per  cent,  of  157  cases,  Frerichs  in  15  per  cent,  of  41  cases, 
Lecorche  in  22  per  cent,  of  2.S()  cases.  Kales  in  28  per  cent,  of  100 
cases  of  chronic  kidney  disease,  ]\Iiles  Miley  in  31  per  cent,  of 
164  cases  of  acute  and  chronic  kidney  disease,  Galezowski  in  31 
per  cent,  of  154  cases. 

1  Ueber,  Blutuntcrsuchungen  bei  Glaucomkranken,  Graefe's  Arch.  f.  Ophthal., 
Ixxxiii,  547. 

*  Henderson,  Thomas:  Glaucoma,  London,  1910. 


OCULAR  LESIONS  AND  ARTERIAL  PRESSURE  433 

The  duration  of  life  after  the  first  retinal  changes  were  noted:  Bull 
reported  103  cases:  86  of  the  patients  died,  57  within  the  first 
year,  18  in  the  second  year,  6  in  the  third  year,  4  in  the  fourth 
year,  and  1  in  the  sixth  year  of  observation,  making  87  per  cent, 
in  the  first  two  years.  Miles  Miley,  in  164  patients  with  acute 
or  chronic  kidney  disease,  found  105  with  healthy  eyes  and  51  with 
retinitis  albuminurica  (the  other  8  had  affections  of  the  eyes  which 
are  not  pertinent  to  our  subject);  27  per  cent,  of  the  former  and 
53  per  cent,  of  the  latter  died.  The  mortality  shown  among  those 
having  retinitis  albuminurica  was  twice  as  great  as  among  patients 
with  healthy  eyes.  Most  of  the  patients  lived  about  twelve  months 
after  the  first  indications  of  retinal  changes,  two  lived  nearly 
fourteen  months,  and  one  about  eighteen  months.  In  those  cases 
in  which  the  onset  of  the  retinal  disturbance  could  be  definitely 
established  the  average  duration  of  life  did  not  exceed  six  months^ 
(see  page  302). 

The  existence  of  high  systemic  blood-pressure  is  of  ophthalmo- 
logical  interest  in  relation  to  postoperative  hemorrhage  after  cataract 
extraction  and  in  spontaneous  subconjunctival  hemorrhages,  although 
the  latter  may  for  other  reasons  occur  with  normsil  or  even  low  arte- 
rial tension.  The  higher  the  arterial  tension,  the  less  favorable  is 
the  case  from  an  operative  stand-point.  In  such  cases  vasodilators 
may  be  administered  to  reduce  pressure  during  the  operation. 
Morphin  is  also  useful,  since  it  helps  to  prevent  the  emotional 
disturbance  with  which  a  cataract  extraction  is  of  necessity  asso- 
ciated, and  which  has  such  a  potent  pressor  eft'ect.^ 

Spasm  of  the  retinal  arteries  of  variable  duration  and  of  not 
infrequent  recurrence  is  now  a  well-established  ophthalmological 
entity.  The  vascular  spasm  has  been  observed  in  its  incipience 
and  disappearance  by  means  of  the  ophthalmoscope.  There  seems 
to  be  a  growing  conviction  that  a  number  of  the  cases  which  were 
previously  attributed  to  embolism  were  really  instances  of  spastic 
arterial  contraction.  The  literature  on  the  subject  has  been  sum- 
marized by  Zentmayer,^  who  also  reported  a  case  in  which  he 
repeatedly  observed  a  spasm  of  the  central  retinal  artery.  The 
condition  is  generally  associated  with  arteriosclerosis  and  hyper- 


*  Quoted  by  Posey,  W.  C:     The  Significance  of  Ocular  Findings  in  Estimating 
Longevity,  Jour.  Am.  Med.  Assn.,  1913,  Ix,  1867. 

*  Reber  found  a  rise  of  pressure  of  30  mm.  occasioned  by  the  psychic  stimulation 
incident  to  preparation  for  a  cataract  extraction. 

'  Some  Unusual  Ocular  Manifestations  of  Arteriosclerosis,  Jour.  Am.  Med.  Assn., 
1906. 

28 


434  OPHTHALMOLOGY 

tension,  and  causes  temporary  blindness,  usually  of  the  hemianopic 
type  (Peter)  ^  (see  Vascular  Crises,  page  264). 

Pulsation  of  the  Retinal  Vessels. — Blood-pressure  in  the  oph- 
thalmic artery  of  animals  is  only  a  few  millimeters  Hg.  below  that 
of  the  carotid.  While  this  relation  may  not  hold  good  for  man, 
arterial  pressure  is  well  above  the  intra-ocular  tension.  Under 
normal  conditions  the  vascular  pulsation  cannot  be  ophthalmo- 
scopically  demonstrated,  probably  because  the  pulsatile  movement 
is  damped  by  the  intra-ocular  tension,  and  because  it  is  spread 
over  the  large  area  of  the  eyeball. 

Under  pathological  conditions,  aortic  insufficiency,  aneurysm, 
exophthalmic  goitre,  etc.,  arterial  pulsation  can  sometimes  be 
seen  either  as  (1)  "  a  true  pulse  wave,  accompanied  by  locomotion 
of  the  vessels,  and  (2)  an  intermittent  flow  of  blood  or  pressure 
pulse.  In  the  latter  instance,  the  arteries  fill  with  blood  only  with 
the  heart  beats,  being  empty  between  them;  and  pulsation  is  only 
visible  upon  the  disk.  This  type  of  pulsation  is  a  pure  pressure 
phenomenon,  and  is  caused  by  any  considerable  increase  of  intra- 
ocular tension  with  normal  or  lowered  blood-pressure,  as  in  glaucoma 
or  by  any  considerable  diminution  of  blood-pressure  with  normal 
intra-ocular  tension,  as  in  syncope,  orbital  tumors,  etc.  The  true 
arterial  pulse  occurs  in  cases  of  aortic  regurgitation  (Quincke)  or 
aneurysm,  in  Graves's  disease,  etc.;  it  is  not  confined  to  the  optic 
disk.  It  is  equally  a  pressure  phenomenon,  but  the  differences  of 
pressure  are  smaller." 

"Capillary  pulsation  is  seen  only  in  aortic  regurgitation  as  a 
systolic  reddening  and  diastolic  paling  of  the  disk."  Venmis  pul- 
sation occurs  in  three  forms:  (1)  the  normal  negative  venous  pulse; 
(2)  the  positive  venous  pulse  (tricuspid  insufficiency),  and  (3)  the 
transmitted  centripetal  venous  pulse  (an  exaggerated  form  of  the 
normal  type  due  to  venous  congestion).^ 

A  careful  ophthalmoscopic  examination,  in  conjunction  with 
blood-pressure  studies,  is  therefore  often  of  the  greatest  value.  It 
should  be  made  with  a  dilated  pupil,  as  minor  degrees  of  vascular 
changes  are  easily  overlooked,  but  strong  mydriatics,  such  as 
atropin,  should  not  be  used  on  account  of  the  danger  of  precipita- 
ting an  attack  of  glaucoma.  De  Schweinitz  recommends  euph- 
thalmin  (3  drops  of  a  5  to  10  per  cent,  solution)  to  be  followed  after 
the  examination  by  the  instillation  of  a  few  drops  of  a  solution 
of  pilocarpin,  gr.  j  to  the  ounce. 

1  Arterial  Hypertension  and  its  Relation  to  Morbid  Changes  in  the  Eye,  Penn. 
Med.  Jour.,  1911,  xiv,  411. 

'  Parsons:  Pathology  of  the  Eye,  1908,  iv,  1254. 


THE  EYE-GROUNDS  IN  ARTERIAL  HYPERTENSION       435 

Visual  Accommodation. — Systemic  blood-pressure  also  bears  a 
relation  to  visual  accommodation  which  is  apt  to  be  better  late  in 
the  day  when  pressure  is  at  its  highest.  Hypotensive  individuals 
often  have  less  accommodative  power.  The  onset  of  'presbyopia  is 
often  concomitant  with  the  beginning  of  arterial  hypertension 
(de  Schweinitz).  Attention  has  also  been  called  by  this  eminent 
author  to  the  fact  that  certain  forms  of  asthenopia,  especially  those 
occurring  in  women  in  the  late  forties,  owe  their  origin  to  angio- 
sclerosis,  and  while  rebellious  to  the  usual  methods  of  treatment, 
yield  to  dietetic  and  therapeutic  measures  which  tend  to  lower 
arterial  tension. 

A  large  percentage  of  the  early  cases  of  increased  blood-pressure 
are  overlooked  unless  the  sphygmomanometer  is  employed,  and 
likewise  many  cases  of  incipient  arteriosclerosis  will  not  be  detected 
if  the  ophthalmoscope  is  not  called  into  requisition.  This  applies 
especially  to  those  cases  in  which  the  arterial  involvement  is  chiefly 
cerebral. 

In  90  cases  of  general  arteriosclerosis  Rahlmann^  found  macro- 
scopic lesions  of  the  vessels  of  the  retina  in  practically  all.  Well- 
marked  changes  occurred  in  about  20  per  cent. 

The  Eye-grounds  in  Arterial  Hypertension. — "The  eye-ground 
lesions  of  persistent  high  arterial  tension,  when  this  is  a  symptom 
of  arteriosclerosis,  may  conveniently  be  divided  into  those  which 
are  suggestive  and  those  which  are  pathognomonic.  The  suggestive 
signs  include  uneven  caliber  and  undue  tortuosity  of  the  retinal 
arteries,  increased  distinctness  of  the  central  light  streak,  and 
unusually  light  color  of  the  breadth  of  the  artery,  and  alterations 
in  the  course  and  caliber  of  the  veins." 

The  pathognomonic  signs  include  changes  in  the  size  and  breadth 
of  the  retinal  arteries  of  such  character  that  a  beaded  appearance 
is  produced;  distinct  loss  of  translucency;  decided  lesions  in  the 
arterial  walls,  consisting  of  white  stripes  in  the  form  of  perivasculitis; 
alternate  contractions  and  dilatations  of  the  veins,  and  particularly 
— and  this  is  the  most  important  of  the  signs — indentation  of  the 
veins  by  the  stiffened  arteries  in  the  same  manner  as  a  solid  rod 
would  indent  a  rubber  tube  when  lying  across  it.  Sometimes  the 
vein  is  simply  flattened  slightly  at  the  point  of  crossing,  or  merely 
pushed  aside,  or  its  caliber  is  contracted  so  that  beyond  the  point 
of  crossing  there  is  an  ampulliform  dilatation.  In  addition  to  these 
clear  signs  there  may  be  changes  in  the  venous  walls  so  that  they 
are  bordered  with  white  stripes.    The  veins  may  be  exceedingly 

'  Quoted  by  de  Schweinitz:     Intra-ocular  Angiosclerosis  and  its  Prognostic  and 
Diagnostic  Significance,  Int«rnat.  Clinics,  series  17,  i,  177. 


436  OPHTHALMOLOGY 

tortuous  and  contain  varicosities.  Finally,  there  are  edema  of  the 
retina  in  the  form  of  gray  opacity  around  the  disk  or  following 
the  course  of  the  vessels;  hemorrhages  manifesting  themselves  as 
linear  extravasations  or  roundi^sh  infiltrations,  or  sometimes  assum- 
ing a  drop-like  form"  (de  Schweinitz).^ 

The  Ocular  Reflex  (Aschner). — If  sufficient  pressure  is  exerted 
upon  the  eyeball  beneath  the  supra-orbital  ridge,  the  eye  being 
turned  downward  so  as  to  avoid  pressure  upon  the  cornea,  a  reflex 
lowering  of  the  pulse  will  normally  occur.  The  reflex  inhibition, 
as  has  been  experimentally  demonstrated,  travels  over  the  fifth 
to  the  tenth  nerve.  The  reflex  has  been  found  exaggerated  in 
epilepsy,  and  in  exophthalmic  goitre.  It  is  not  abolished  by  ether 
anesthesia.  It  is  increased  by  the  administration  of  pilocarpin 
and  diminished  by  atropin.  Considerable  pressure  is  required  to 
bring  about  the  reflex,  and  this  in  turn  entails  a  good  deal  of  pain 
to  the  patient  and  perhaps  danger  to  some  eyes.  It  is  not  a 
procedure  which  can  be  readily  or  frequently  applied,  and  should 
therefore  be  reserved  for  the  study  of  exceptional  cases.  The 
pressure  above  mentioned  will  sometimes  slow  the  pulse  when 
direct  pressure  over  the  vagus  in  the  neck  fails  to  do  so.  It  is  inter- 
esting to  remember  that  Kobinson  and  Draper  have  shown  that  the 
right  vagus  inhibits  the  heart  more  than  does  the  left,  and  similarly 
pressure  over  the  right  eye  seems  to  especially  exert  its  effect  upon 
the  sinus  region  of  the  heart,  whereas  pressure  over  the  left  eye  seems 
to  exert  more  influence  upon  the  conductive  system  (Levine). 

The  reflex  is  said  to  be  positive  when  slowing  of  the  pulse  occurs. 
Normally  when  it  occurs  the  reflex  is  positive.  The  absence  of 
pulse  retardation  or  an  actual  increase  in  rate  occurs  in  sympa- 
thicotonics. In  vagotonics,  on  the  other  hand,  marked  slowing, 
of  the  pulse  occurs.  Indeed,  in  them  pressure  maintenance  for 
ten  to  twelve  seconds  may  cause  syncope  from  complete  temporary 
asystole.  These  symptoms  are  due  to  an  abnormally  low  nervous 
threshold  in  the  vagus  system,  since  they  disappear  under  atropin. ^ 
The  claim  that  the  reflex  is  of  diagnostic  value  in  differentiating 
cardiac  weakness  due  to  myocardial  lesions  from  those  due  to 
nervous  disturbances  has  not  been  substantiated.  It  may  be  of 
some  value  in  differentiating  between  postfebrile  bradycardia  and 
auriculoventricular  heart-block.^  This  reflex  is  generally  absent 
in  tabes  dorsalis. 

'  Loc.  cit. 

'  Neugcbauer,  H. :  Beitr.  z.  Klinik  d.  Vagotonie,  Wien.  klin.  Wchnschr.,  1914, 
xxvii,  1023. 

'  Gunson,  E.  B.:  The  Oculocardiac  Reflex,  British  Jour.  Child,  Dis.,  1915,  xii, 
No.  136,  p.  97. 


INDEX. 


Abdominal  aorta,  paroxysmal  dilata- 
tion of,  268 
Acromegaly,  blood-pressure  in,  367 
Adams-Stokes  syndromes,  blood-press- 
ure and,  250 
Addison's   disease,    blood-pressure   in, 

364 
Adiposity,  blood-pressure  in,  278,  371 
Adrenal  glands,  physiology  of,  35,  290, 
342 
in  nephritis,  289 
insufficiency,  acute,  399 
white  line  in,  271 
Age,  blood-pressure  and,  56 
Aged,  blood-pressure  in  the,  260 
Air,  cold,  effect  on  blood-pressure,  213 
Albuminuria,  blood-pressure  and,  297 

orthostatic,  199 
Alcohol,  blood-pressure  effects  of,  336 
Alcoholism,  blood-pressure  in,  238 
Alkalies,  blood-pressure  and,  337 
Altitudes,  blood-pressure  and,  53,  373 
Ammonium,   blood-pressure  effect  of, 

337 
Amyloid  renal  disease,  283 
Anaphylaxis,  219 
Anemia,  blood-pressure  in,  372 
Aneroid  sphygmomanometer,  112 
Anesthesia,  blood-pressure  during,  423 
chilling  during  blood-pressure  and, 
404 
Anesthetics,  blood-pressure  and,  408 
Aneurysm,  aortic,  blood-pressure  in,  245 

subclavian,  causation  of,  246 

Angina  abdominalis  as  vascular  crisis, 

267 

pectoris  as  vascular  crisis,  265 

Angioneuroses,  blood  flow  in,  271 

Angioneurotic  edema,   vascular   crises 

and,  271 
Aorta,  abdominal,  paroxjsmal  dilata- 
tion of,  268 
Aortic  aneurysm,  blood-pre&sure  in,  245 
insufficiency,  blood-pressure  in,  242 
in  arm  in,  243 
in  leg  in,  243 
Duroziez's  sign  of,  245 
Traube's  sign  of,  245 
obstruction,  blood-i)res,sure  in,  245 


Aortitis,  syphilitic,  blood-pressure  in, 

222  298 
Apoplexy,  270,  305,  311,  390 

in  vascular  crises,  270 
Arm,  blood-pressure  in,  in  aortic  insuffi- 
ciency, 243 
estimation  of  blood  flow  in,  173 
Arrhythmia,  extrasystolic,  blood-press- 
ure in,  249 
Arsenic   poisoning,    blood-pressure   in, 

235 
Arterial    blood-pressure,    constitution- 
ally low,  193 
function,  estimation  of,  180 
hypertension,  310 
pressure,  ocular  lesions  due  to,  429 
tonus,  estimation  of,  182 

Vries-Reilingh's  method, 
182 
Arteries  in  arteriosclerosis,  261 

coronary,  effect  of  epinephrin,  342 
effects  of  alterations  of  blood-press- 
ure on,  58 
fimctional  tests  of,  263 
physiology  of,  29 
retinal,  blood-pressure  in,  425 
pulsation  of,  434 
spasm  of,  433 
in  symptoms  of  arterial  hyperten- 
sion, 279 
Arteriocapillary  index  in  blood-press- 
ure, 264 
Arterioles,    effects    of    alterations    of 
blood-pressure  on,  58 
physiology  of,  30 
Arteriosclerosis,  arteries  in,  261 

bilateral  variations  of  pressure  in, 

261 
blood-pressure  in,  258 

in  tobacco  poisoning,  235 
ice  reaction  in,  263 
nitrite  test  of,  263 
stasis  reaction  in,  263 
vascular  reactions  in,  261 
Aspiration    of    pleura,    blood-pressure 

effect  of,  406 
Asthma,  bronchial,  blood-pressure  in, 

257 
Athletics,  blood-pressure  and,  49,  154, 

315,  382 
Atropin,  blood-prossure  effect  of,  337 


438 


INDEX 


Aural  symptoms  of  arterial  hyperten- 
sion, 279 

Auricular  fibrillation,  blood-pressure  in, 
250 

Auscultatory  determination  of  blood- 
pressure,  223  , 
phases,  duration  of,  213 

Auto-intoxication,    blood-pressure    in , 
365 

Aviation,  circulatory  symptoms  in,  205 


B 


Bajardi's  ocular  sphygmomanometer, 

426 
Barach's    formula    of    blood-pressure 

quotient,  168 
Barometric  pressure,  375 
Benedick's  sphygmomanometer,  86 
Berberin,  blood-pressure  effect  of,  346 
Bichloride  of  mercury  poisoning,  307 
BUiary  colic  and  vascular  crisis,  269 
Bing's  sphygmomanometer,  109 
Birth,  blood-pressure  at,  378 
Bishop's  sphygmomanometer,  82 
Bladder  drainage,  effect  on  blood-press- 
ure, 407 
Bleeding.    See  Hemorrhage,   phlebot- 
omy, 326,  372,  400 
Blood  and  blood-pressure,  36 
flow  in  angioneuroses,  271 
blood-pressure  and,  37 
estimation  of,  170 
in  arm,  173 

Bornstein's  method,  178 
djTiamic  diagrams  in,  187 
Fellner's  method,  178 
Hewlett's  method,  177 
Stewart's  method,  170 
plethysmograph  in,  173 
tachograph  in,  180 
Van      Zwaluwenburg's 

method,  177 
von  Kries's  method,  180 
in  fevers,  205 
renal  function  and,  292 
systolic  output,  estimation  of,  by 
venous  pressure,  171 
Blood-pressure,  absolute  sphygmogram 
;        in,  164 

in  acromegaly,  367 

in  acute  endocarditis,  241 

nephritis,  306 
in  Adams-Stokes  syndromes,  250 
in  Addison's  disease,  364 
in  adiposity,  278,  371 
age  and,  56 
in  aged,  260 
albuminuria  and,  297 
alcohol  and,  336 
in  alcoholism,  238 
alkalies  and,  337 


Blood-pressure,  alterations  of,    effects 
of,  on  arteries,  58 
on  arterioles,  58 
on  capillary  pressure,  58 
on  heart,  57 
on  kidneys,  59 
on  organs  of  body,  57 
on  pulmonary  pressure,  58 
on  venous  pressure,  58 

altitudes  and,  53,  373 

ammonium  and,  337 

in  anemia,  372 

anesthetics  and,  423 

in  aortic  aneurysm,  245 
insufficiency,  242 
obstruction,  245 

in  arm,  in  aortic  insufficiency,  242 

in  arsenic  poisoning,  235 

arterial,  constitutionally  low,  193 

arteriocapillary  index,  264 

in  arteriosclerosis,  258 

in  aspiration  of  pleura,  406 

athletics  and,  49,  154,  316,  382 

atropin  and,  337 

in  auricular  fibrillation,  250 

in  auto-intoxication,  365 

bandaging  of  extremities  and,  327 

and  barometric  pressure,  375 

berberin  and,  346 

in  bichloride  of  mercury  poisoning, 
307 

at  birth,  378 

blood  in,  36 

flow  and,  37 

in  bradycardia,  250 

bromides  and,  342 

in  bronchial  asthma,  257 

in  cachexia,  373 

caffein  and,  338 

camphor  and,  339 

capillary,  estimation  of,  183 

in  carcinoma,  373 

cardiac  cycle  in,  25 

in  cardiac  disease,  240 

in  cerebral  hemorrhages,  389 

chemical  regulation  of,  35 

in  Cheyne-Stokes  respiration,  300 

in  childhood,  56,  377 

chilling  during  anesthesia  and,  404 

chloral  and,  342 

after  clilorin-gas  inhalation,  235 

chloroform  and,  408 

in  chlorosis,  372 

in  cholera,  207 

and  climate,  375 

cocain  and,  410 

in  collapse,  219 

counter-irritation  and,  331 

cuff,  62 

location  of,  65 

in  delirium  tremens,  238 

in  dementia  precox,  388 

in  diabetes,  360 


INDEX 


439 


Blood-pressure,  diastolic,  39,  134,  274 
diet  and,  317 
digestion,  effect  of,  52 
digitalis  and,  339 
in  diphtheria,  207 
in  diseases  of  heart,  240 

of  myocardium,  249 

of  nervous  system,  386 
during  anesthesia,  423 
and  dysmenorrhea,  417 
in  eclampsia,  421 
edema  and,  248 
electricity  and,  328 
in  encephalopathy,  234 

treatment  of,  235 
in  epilepsy,  388 
epinephrin  qjid,  342 
ergot  and,  344 

erythrol  tetranitrate  and,  350 
estimation  of,  61 

accuracy  of,  133 

auscultatory,  69 

graphic  method  of,  87 

instrumental,  61 

oscillatory  method  of,  108 

palpatory,  65 

personal  equation  of  examiner 
in,  131 

possible  accidents  in,  133 

precautions  in,  129 

sources  of,  error  in,  126 

subjective  method  of,  123 

technic  of,  129 

value  of,  133 

visual  method  of,  108 
ether  and,  408 
ethyl  chloride  and,  409 
exercise  and,  49,  155,  316,  382 
in  exogenous  intoxications,  232 
in  exophthalmic  goitre,  367 
in  extrasystolic  arrhythmia,  249 
in  extra-uterine  pregnancy,  422 
extremes,  compatible  with  life,  136 
factors  maintaining,  24 

regulating,  24 
feeding  and,  52 
fluid  intake  and,  320 
fresh  air  and,  213 
in  gastro-enteritis,  385 
glandular  extracts  and,  366 
in  glaucoma,  431 
gonads,  effect  of,  419 
in  gout,  363 
normal  an'd,  346 
heart  in,  25 
in  heart-block,  250 
in  hemiplegia,  391 
in  hemorrhage,  372,  400 
in  hemorrhages  of  brain,  389 
hemic  viscosity  and,  308 
hydrastinin  and,  346 
hydrastis  and,  345 
hydrotherapy  and,  320 


Blood-pressure  in  hydrothorax,  230 
in  hyperemesis  gravidarum,  422 
hyperglycemia  and,  295,  360 
in  infant^,  377 
in  infectious  diseases,  204 
acute,  207 
chronic,  222 
treatment  of,  217 
instruments,  choice  of,  137 

classification  of,  139 

different  types  of,  139 

graphic  registration,  92 
intra-abdominal,  44 

estimation  of,  191 

Moritz's  method,  191 

increased,  268 
intracranial,  45 
intra-ocular,  46 
intrapericardial,  44 
iodides  and,  346 
in  jaundice,  364 
kidneys  and,  284,  296 
in  lead  poisoning,  232 
in  leg,  in  aortic  insufficiency,  243 
in  lenticular  cataract,  429 
life  insurance  and,  376 
in  locomotor  ataxia,  392 
in  lumbar  puncture,  411 
lymph  flow  and,  36 
in  malaria,  209 

manipulations    of    pelvic    viscera 
and,  405 

of  thoracic  viscera  and,  405 
mannitol  nitrate  and,  350 
massage  and,  330 
maximum,  22 
mean,  estimation  of,  39 
measurement  of,  method  of,  19 
in  meningitis,  cerebrospinal,  210 

tuberculous,  210 
in  menopause,  418 
in  menstruation,  417 
in  mental  diseases,  387 
in  mercurial  poisoning,  307 
in  metabolic  diseases,  360 
minimum,  22 
mistletoe  and,  347 
in  mitral  insufficiency,  246 

obstruction,  248 

stenosis,  248 
morphin  and,  351 
in  morphinism,  239 
muscular  exertion  in,  50,  155,  316, 

382 
in  myxedema,  371 
Nauheim  baths  and,  321 
neosalvarsan,  355 
in  nephritis,  281 
in  neurasthenia,  386 
in  neuroses,  386 
nitrites  and,  347 
nitrogen  retention  and,  295 
nitroglycerin  and,  349,  350 


440 


INDEX 


Blood-pressure,  nitrous  oxide  and,  409 
normal,  56,  378 

rule  for  estimating,  377 
in  obstetrics,  394 
ocular  tension  and,  425 
in  old  age,  2(50 

in  ophthalmology,  425  ' 

opium  and,  351 

orthostatic  albuminuria  and,  199 
pancreas  extract  and,  289 
in  paracentesis  abdominalis,  406 
para-oxyphenylethylamin  and,  345 
in  paratyphoid  fever,  215 
in  paresis,  393 
in  paroxysmal  dyspnea,  298 
passive  change  of  posture  in,  154 
pediatrics  and,  377 
in  pericardial  effusions,  256 
phlebotomy  and,  327 
in  phosphorus  poisoning,  235 
physical  efficiency  and,  379 
pituitary  extract  and,  352 
in  pleural  effusions,  229 
in  pneumonia,  211 
in  pneumothorax,  230 
in  polycythemia,  307 
postural  response  in,  152 
posture  and,  51 

patient  and,  403 
in  pregnancy,  419 
at  puberty,  378 
in  pulmonary  edema,  301 

hemorrhage,  227 
pulse,  40 

in  pulsus  alternans,  250 
purgation  and,  314 
quotient,  165 

Barach's  formula,  168 

Erlanger   and   Hooker's   for- 
mula, 167 

Fuerst    and    Soetbeer's    for- 
mula, 167 

Tigerstedt  formula,  166 

von     Recklinghausen's     for- 
mula, 168 
radio-active  substances  in,  333 
renal  decapsulation  and,  335 
respiration  and,  40 
in  retinal  arteries,  425 

hemorrhages,  432 
salvarsan  and,  354 
'      in  scarlet  fever,  214 
secretion  and,  49 

of  urine  and,  296 
in  senility,  260 
in  shock,  219 

treatment  of,  220 
significance  of,  137 
sleep  and,  53,  315 
in  smallpox,  215 

sodium  chloride  metabolism  and, 
296 

nitrite  and,  350 


Blood-pressure  in  spinal  anesthesia,  412 

in  status  lymphaticus,  371 

strophanthus  and,  353 

strychnin  and,  355 

in  surgery,  394 

in  surgical  hemorrhage,  400 
shock,  396 

in  syphilis,  222 

in  syphilitic  aortitis,  298 
myocarditis,  249 

in  syringomyelia,  393 

systolic,  39 

in  tachycardia,  250 
paroxysmal,  250 

testes  and,  419 

throughout  vascular  tree,  23 

thyroid  extract  and,  355 

tissue  extracts  and,  366 

in  tobacco  poisoning,  235 

arteriosclerosis  and,  237 

tropical  climates  and,  375 

in  tuberculosis,  223 

in  tumors  of  brain,  389 

in  typhoid  fever,  215 

in  uremia,  298 

urethane  and,  356 

vasotonin  and,  356 

venous,  23,  27 
in  shock,  398 

visceral  manipulations  and,  404 

visual  accommodation  and,  435 

yohimbin  and,  356 
Bloodvessels,  resistance  of,  estimation 

of,  180 
Bornstein's   method   of  estimation   of 

blood  flow,  178 
Bouloumie's  sphygmomanometer,  123 
Bradycardia,  blood-pressure  in,  250 
Brain,  hemorrhages  of,  blood-pressure 
in,  389 

tumors  of,  blood-pressure  in,  389 
Bromides,  blood-pressure  and,  342 
Bronchial   asthma,    blood-pressure   in, 

257 
Brugsch's  sphygmomanometer,  102 
Bussenius's  sphygmomanometer,  106 


Cachexia,  blood-pressure  in,  373 
Caffein,  blood-pressure  and,  338 
Camphor,  blood-pressure  and,  339 
Capillaries,  physiology  of,  30 
Capillarv  blood-pressure,  estimation  of, 
144,  183 
pressure,  effects  of  alterations  of 
arterial  pressure  en,  58 
Carbon    monoxide    poisoning,     blood- 
pressure  in,  239 
Carcinoma,  blood-pressure  in,  373 
Cardiac  action,  venous  pressure  and, 
149 


INUEX 


441 


Cardiac  cycle  and  blood-pressure,  25 
disease,  blood-pressure  in,  240 
load,  275 
rate,  28 
tone,  28 
Cardiovascular  disease,  arterial  hyper- 
tension in,  274 
symptoms  in  arterial  hypertension, 
278 
Cataract,  lenticular,  blood-pressure  in, 

429 
Cerebral   hemorrhages,   blood-pressure 
in,  389 
vascular  crises,  269 
Cerebrospinal  meningitis,  blood-press- 
ure, 210 
pressure  in  blood-pressure,  390,  412 
Cervical  rib,  effect  on  blood-pressure  in 

the  arm,  246 
Chemical  regulation  of  blood-pressure, 

35 
Cheyne-Stokes  respiration,  blood-press- 
ure in,  300 
Chilblains,  vascular  crises  and,  271 
Childhood,  blood-pressure  in,  377 
Chloral,  blood-pressure  effect  of,  342 
Chlorin-gas  poisoning,  235 
Chloroform,   blood-pressure   effect   of, 
408 
in  pulmonary  hemorrhage,  228 
Chlorosis,  372 

Cholera,  blood-pressure  in,  207 
Cholesterinemia  and  hypertension,  290 
Christen's  energometer,  190 
Circulation,  functional  efficiency  of,  151 
amplitude  frequency  pro- 
duct of,  168 
Crampton's  table  of,  152 
energy  index  in,  168 
Graupner's  test  of,  157 
Katzenstein's  test  of,  161 
Claudication,  intermittent,  in  vascular 

crises,  270 
Climate,  375 

Cocain,  blood-pressure  effect  of,  410 
Colic,  biliary,  in  vascular  crises,  269 

renal,  in  vascular  crises,  269 
Collapse,  blood-pressure  in,  219 
Conduction  of  pulse  waves,  128 
Coronary  arteries,  effect  of  drugs  on, 

357 
Corpulence,  278,  371 
Cramps  in  the  legs,  treatment  of,  273 
Crbmpton's    table    of   functional    effi- 
ciency of  circulation,  152 
Critical  venous  pressure,  26 
Cuff,  blood-pressure,  62 


Decompensation  and  venous  blood- 
pressure,  341 


Delirium  tremens,   blood-preseure  in, 

238 
Dementia  precox,  blood-pressure  in,  388 
Depressor  nerve,  physiology  of,  33 
Dermographism,   vascular  crises  and, 

271 
Diabetes,  blood-pressure  in,  360 
Diastole,  time  relations  of,  25 
Diastolic  pressure,  definition  of,  17 
estimation  of,  67,  125 
by  palpation,  68 
significance  of,  134 
by  visualization,  68 
Diet,  blood-pressure  and,  317 

in  hypertension,  317 
Digestion,  effect  on  blood-pressure,  52 
Digitalis,  blood-pressure  effect  of,  339 
in  failing  compensation,  340 
in  high-pressure  stasis,  340 
in  piilmonary  hemorrhage,  227 
Dilatation,  paroxysmal,  of  abdominal 

aorta,  268 
Diphtheria,  blood-pressure  in,  207 
Dysmenorrhea  and  blood-pressure,  417 
Dyspnea,   paroxysmal,   blood-pressure 

in,  298 
Drugs,  effects  of,  on  blood-pressure,  336 
on  coronary  arteries,  357 
on  vasomotor  system,  220 
on  venous  pressure,  358 
Duroziez's  sign  of  aortic  insufficiency, 

245 
Dynamic   diagrams   in   estimation   of 
blood  flow,  187 


Eclampsia,  blood-pressure  in,  421 
Edema,  angioneurotic,  vascular  crises 
and,  271  . 
blood-pressure  and,  248 
pulmonary,  blood-pressure  in,  301 
sodium  chloride  and,  296 
Ehret's  phenomenon,  68 
Electricity,  blood-pressure  and,  328 
Encephalopathy,  blood-pressure  in,  234 
End  pressure,  definition  of,  18 
Endocarditis,  acute,  blood-pressure  in, 

241 
Energometer,  Christen's,  190 
Energy  index  in  functional  efficiency 

of  circulation,  168 
Enteroclysis  in  hypertension,  315 
Epilepsy,  blood-pressure  in,  388 
Epinephrin,  blood-pressure  and,  35,  342 
Ergot,  blood-pressure  and,  344 

in  pulnilonary  hemorrhage,  228 
Erlanger    and    Hooker's    formula  for 

blood-pressure  quotient,  167 
Erlanger's  sphygmomanometer,  96 
Erythrol    tetranitrate,    blood-press^ure 

and,  350 


442 


INDEX 


Erythromelalgia,  270 

Ether,  blood-pressure  effect  of,  408 

Ethyl  chloride,  blood-pressure  effect  of, 
409 

Exercise,  blood-pressure  and,  49,  155, 
316,  382 

Exogenous  intoxications,  blood-press- 
ure in,  232 

Exophthalmic  goitre,  blood-pressure  in, 
367 

Extrasystolic  arrhythmia,  blood-press- 
ure in,  249 

Extra-uterine  pregnancy,  blood-press- 
ure in,  422 

Eye-grounds  in  arterial  hypertension, 
435 


Fasting,  effect  on  blood-pressure,  317 
Faught's  sphygmomanometer,  78 
Fedd6's  oscillometer,  1 10 
Feeding,  blood-pressure  and,  52 
Fellner's  method  of  estimation  of  blood 

flow,  178 
Fevers,  blood  flow  in,  205 
Fibrillation,    auricular,    blood-pressure 

in,  250 
Fibromyomata    uteri,     blood-pressure 

and,  423 
Finger  plethysmograph,  Fleischer's,  175 
Fleischer's  finger  plethysmograph,  175 

sphygmomanometer,  105 
Fluid  intake,  blood-pressure  and,  320 
Francois  Frank's  sphygmomanometer, 

123 
Frank  and  Reh's  method  of  estimation 

of  venous  pressure,  142 
Frey's  method  of  estimation  of  venous 

pressure,  141 
Fuerst  and  Soetbeer's  formula  of  blood- 
pressure  quotient,  167 
Function,  arterial,  estimation  of,  180 
Functional  capacity  of  heart,  151 
efficiency  of  circulation,  151 
hypotension,  240 
tests  of  arteries,  263 


O 


GaIitnbr's   method   of  estimation   of 
venous  pressure,  140 
phenomenon,  140 
sphygmomanometer,  80 
Gastro-enteritis,  blood-pressure  in,  385 
Gastro-intestinal  symptoms  of  arterial 

hypertension,  278 
Gibson's  sphygmomanometer,  93 
Glandular  extracts,  blood-pressure  and, 

366 
Glaucoma,  blood-pressure  in,  431 
Goitre,  exoi)hthalmic,  367 


Gonads,  effect  on  blood-pressure,  36, 
419 

Gout,  blood-pressure  in,  363 

Graphic  method  of  estimation  of  blood- 
pressure,  87 

Graupner's  test  of  functional  efficiency 
of  circlilation,'  157 


Heart  and  blood-pressure,  25 

block,  blood-pressure  and,  250 
diseases  of,  blood-pressure  in,  240 
effects  of    alterations   of    blood- 
pressure  on,  58 
functional  capacity  of,  151 
symptoms  of    arterial    hyperten- 
sion, 279 
work  done  by,  310 
Heat  and  cold  applied  to  the  abdomen, 

415 
Hemic  viscosity,   blood-pressure  and, 

308 
Hemiplegia,  blood-pressure  in,  391 
Hemoglobinuria,  vasomotor,  201 
Hemorrhage,  blood-pressure  in,  372,  400 
Hemorrhages  of  brain,  blood-pressure 
in,  389 
pulmonary,  blood-pressure  in,  227 
retinal,  blood-pressure  in,  432 
surgical,  blood-pressure  in,  400 
Hertz's  sphygmomanometer,  85 
Hewlett's    method    of    estimation    of 

blood  flow,  177 
Hill's  sphygmomanometer,  77 
Hooker  and  Eyster's  method  of  estima- 
tion of  venous  pressure,  142 
Hormonal,  blood-pressure  and,  346 
Howell's  method  of  estimation  of  ven- 
ous pressure,  142 
Hiirthle's  manometer,  20 
Hydrastinin,  blood-pressure  effects  of, 

346 
Hydrastis,  blood-pressure  effects  of,  345 
Hydrotherapy,  blood-pressure  and,  320 
Hydrothorax,  blood-pressure  in,  230 
Hyperemesis   gravidarum,  blood-press- 
ure in,  422 
Hyperglycemia  and  hypertension,  295, 

360 
Hyperpiesis,  281 
Hypertension,  arterial,  310 

bandaging  of  extremities  in,327 
blood  volume  in,  275 
in  cardiovascular  disease,  310 
cholesterinemia  and,  290 
climate  in,  332 
complications  of,  298 
conservation  of  energy  in,  319 
counter-irritation  in,  331 
diet  in,  317 
electricity  in,  328 


INDEX 


443 


Hypertension,  arterial,  exercise  in,  316 
eye-grounds  in,  435 
fluid  intake  in,  320 
hemic  viscosity  and,  308 
hydrotherapy  in,  320 
massage  in,  330 
Nauheim  baths  in,  321' 
phlebotomy  in,  327 
prognosis  of,  302 
radio-active  substances  in,  333 
respiratory  gymnastics  in,  332 
retinal  hemorrhages  in,  432 
specific  treatment  in,  222 
surgical  treatment  in,  335 
symptoms  of,  278 
arteries,  279 
aural,  279 
cardiovascular,  278 
gastro-intestinal,  278 
heart  in,  279 
nervous,  278 
ocular,  278 
renal,  278 
signs  in,  279 
treatment  of,  310 
psychic,  332 
hyperglycemia  and,  295,  360 
in  nephritis,  281 
etiology  of,  283 
symptoms  of,  282 
nitrogen  retention  and,  295 
renal  circulation  and,  292 

function  and,  292 
secretion  of  urine  in,  293 
viscosity  and,  308 
Hyperthyroidism,  367 
Hypnosis,  156 
Hypotension,  193 
causes  of,  193 
etiology  of,  196 
extreme,  prolonged,  373 
functional,  240 
in  lumbago,  201 
mechanical,  240 
in  myalgia,  201 
in  neuritis,  201 
in  phosphaturia,  201 
in  rheumatoid  arthritis,  201 

treatment  of,  201 
in  sciatica,  201 
in  status  lymphaticus,  201 
symptoms  of,  193 
terminal,  240 
treatment  of  infectious  disease,  217 


Infectious  diseases,  blood-pressure  in, 
204 
venous  pressure  in,  207 
Insufficiency,  mitral,  blood-pressure  in, 
246 


Intermittent  claudication,  270 
Intoxications,  exogenous,  blood-press- 
ure in,  232 
Intra-abdominal  pressure,  44 
estimation  of,  191 
increased,  268 
Intracranial  blood-pressure,  45 
Intra-ocular  blood-pressure,  46 

pressure,  venous  pressure  and,  427 
tension,  estimation  of,  428 
Intrapericardial  blood-pressure,  44,  256 
Intravenous  injection,  venous  pressure 

and, 150 
Iodides,  blood-pressure  and,  346 


Jacqxjet's  sphygmotonograph,  92 
Janeway's  sphygmomanometer,  76 
Jaundice,  blood-pressure  in,  364 


Katzenstein's  test  of  functional  effi- 
ciency of  circulation,  161 
Kidney,  decapsulation  and  blood-press- 
ure, 335 
Kidneys,  amyloid  disease  of,  283,  286 
blood-pressure  and,  283,  287 
effects  of  alteration  of  blood-press- 
ure on,  59,  292,  296 
nephritis,  283,  286 
tuberculosis  of,  283 


Lateral  pressure,  definition  of,  18 
Lead  poisoning,  blood-pressure  in,  232 
Leg,  blood-pressure  in,  in  aortic  insuffi- 
ciency, 243 
Lenticular  cataract,  blood-pressure  in, 

429 
Life  insurance,  blood-pressure  and,  376 
Locomotor  ataxia,   blood-pressure  in, 

392 
Lumbago,  hypotension  in,  201 
Lumbar  puncture,   blood-pressure   in, 

411 
Lymph  circulation  and  in  blood-press- 
ure, 36 


M 


Malaria,  blood-pressure  in,  209 
Malingering,  detection  of,  386 
Mannitol  nitrate,  blood-pressure  effect 

of,  350 
Manometer,  Hiirthle's,  21 
maximum,  22 


444 


INDEX 


Manometer,  mercury,  19 

minimum,  22.     See  Sphygmoman- 
ometer. 

Manometers,  spring,  in  estimation  of 
venous  pressure,  140 

Massage,  blood-pressure  and,  330 

Mean  pressure,  definition  of,  17 
rule  for  estimating,  39 

Mechanical  hypotension,  240 

Meningitis,  cerebrospinal,  blood-press- 
ure in,  210 
tuberculous,  blood-pressure  in,  210 

Menopause,  blood-pressure  in,  418 

Menstruation,  blood-pressure  during, 
417 

Mental  diseases,  blood-pressure  in,  387 
work,  physiology  of,  33 

Mercer's  sphygmomanometer,  76 

Mercurial  poisoning,  blood-pressure  in, 
307 

Mercury  manometer,  19 

Metabolic  diseases,  blood-pressure  in, 
360 

Metabolism,  sodium  chloride,  blood- 
pressure  and,  296 

Mistletoe,  blood-pressure  and,  347 

Mitral  insufficiency,  blood-pressure  in, 
246 
obstruction,  blood-pressure  in,  248 
stenosis,  blood-pressure  in,  248 

Momburg's  belt  constriction,  414 

Moritz  and  Tabora,  intravenous  needle 
of,  in  estimation  of  venous  pressure, 
143 

Moritz's  method  of  estimating  intra- 
abdominal pressure,  191 

Morphin,  blood-pressure  and,  351 

Morphinism,  blood-pressure  in,  239 

Muenzer's  sphygmomanometer,  103 

Muscular  exertion  in  blood-pressure, 
50,  155,  316,  382 

Myalgia,  hypotension  in,  2Q1 

Myocarditis,  syphilitic,  249 

Myocardium,  blood-pressure  in  diseases 
of,  249 

Myofibroma,  blood-pressure  and,  423 

Myxedema,  blood-pressure  and,  371 


N 


NAuHEiM  baths,  ])lood-pressure  effects 

of,  321 
Neosalvarsan,  effect  on  blood-pressure, 

355 
Nephritis,  acute,  blood-pressure  in,  306 
chronic,  blood-pressure  in,  281 
hypertension  in,  281 
Nerve,  depressor,  physiology  of,  33 
Nervous  symptoms  of  arterial  hyper- 
tension, 278 
system,  diseases  of,  blood-pressure 
in,  386 


Neurasthenia,  blood-pressure  in,  386 
Neuritis,  hypotension  in,  201 
Neuroses,  blood-pressure  in,  386 
Nicholson's  sphygmomanometer,  74 
Nitrite  test  of  arteriosclerosis,  263 
Nitrites,  blood-pressure  and,  347 

in  pulmonary  hemorrhage,  228 
Nitrogen  retention  and  blood-pressure, 

295,  297 
Nitroglycerin,  blood-pressure  effects  of, 

349,  350 
Nitrous  oxide,  blood-pressure  and,  409 
Normal  arterial  blood-pressure,  56,  378 
venous  blood-pressure,  147 


Obstetrics,  blood-pressure  in,  394 
Obstruction,  aortic,  blood-pressure  in, 
245 
mitral,  blood-pressure  in,  248 
Ocular  sphygmomanometer,  Bajardi's, 
426 
Rubino's,  426 
symptoms  of  arterial  hypertension, 
278 
Old  age,  blood-pressure  during,  260 
Oliver's  sphygmomanometer,  85 
Ophthalmology,  blood-pressure  in,  425 
Opium,  blood-pressure  and,  351 
Orthostatic  albuminuria,  199 

blood-pressure  and,  199 
Oscillations  of  first  order,  17 
of  second  order,  17 
of  third  order,  18 
Oscillatory   method   of   estimation   of 

blood-pressure,  108 
Oscillomanometer,  Widmer,  112 
Oscillometer,  Fedde's,  110 
Ovaries  and  vasomotor  reactions,  418 


Pachon's  sphygmomanometer,  112 

Palpatory  estimation  of  blood-pressure, 
65 

Pal's  sphygmoscope,  108 

Pancreas  extract,  effect  on  blood-press- 
ure, 289 

Paracentesis  abdominalis,  blood-press- 
ure effects  of,  406 

Paratyphoid  fever,  blood-pressure  in, 
215 

Paresis,  blood-pressure  in,  393 

Para-oxyphenylethylamin,  blood-press- 
ure and,  345 

Paroxysmal    dilatation    of   abdominal 
aorta,  268 
dyspnea,  blood-pressure  in,  298 
tachycardia,  blood-pressure  in,  250 

Pediatrics,  blood-pressure  and,  377 


INDEX 


445 


Pelvic  viscera,  manipulations  of,  and 

blood-pressure,  405 
Periarteritis  nodosa,  371 
Pericardial  effusions,  l^lood-pressure  in, 

256 
Phases,  auscultatory,  213 

relative  duration  of,  213 
Phenomenon,  Gartner's,  140 
Phlebotomy,  blood-pressure  and,  227, 

327,  394 
Phosphaturia,  hypotension  in,  201 
Phosphorous  poisoning,  blood-pressure 

in,  235 
Physical  efficiency  and  blood-pressure, 

379 
Physiology  of  arteries,  29 
of  arterioles,  31 
of  capillaries,  30 
of  depressor  nerve,  33 
of  mental  work,  33 
of  vasoconstrictor  system,  32 
of  vasodilator  nerves,  34 

system,  34 
of  vasomotor  system,  31 
of  veins,  30 
Pilocarpin,  352 
Pituitary  extract,  blood-pressure  and, 

352 
Pituitrin  in  pulmonary  hemorrhage,  228 
Plethysmograjjh  in  estimation  of  blood 
flow,  173 
Fleischer's  finger,  175 
Pleura,  aspiraticn  of,  effect  on  blood- 
pressure,  406 
Pleural  effusions,  blood-pressure  in,  229 
Pneumonia,  blood-pressure  in,  211 
Pneumothorax,  blood-pressure  in,  230 
Poisoning,   arsenic,   blood-pressure  in, 
235 
lead,  blood-pressure  in,  232 
mercurial,  blood-pressure  in,  307 
phosphorus,  blood-pressure  in,  235 
tobacco,  blood-pressure  in,  235 
Polycythemia,  blood-pressure  in,  307 
Postural  response  in  blood-pressure,  152 
Posture,  blood-pressure  and,  51 

effect  on  readings  from  right  and 

left  arm,  155 
passive  change  of,  154 
Potain's  sphygmomanometer,  122 
Pregnancy,  blood-pressure  and  viscos- 
ity, 309 
extra-uterine,    blood-pressure    in, 

422 
normal,  blood-pressure  in,  419 
Pressure,  diastolic,  definition  of,  17 
lateral,  definition  of,  18 
mean,  definition  of,  17 
estimation  of,  39 
■  normal,  56,  378 
pulse,  definition  of,  17 
sj'stolic,  definition  of,  17 
venous,  140 


Puberty  and  blood-pressure,  378 
Pulmonary  artery,  effect  of  drugs  upon, 
359 
edema,  blood-pressure  in,  301 
hemorrhage,  blood-pressure  in,  227 
chloroform  in,  228 
digitalis,  227 
ergot  in,  228 
nitrites  in,  228 
pituitrin  in,  228 
treatment  of,  227 
pressure,   effects  of  alterations  of 
blood-pressure  on,  58 
Pulse,  blood-pre&sure  and,  40,  253 
deficit,  251 
pressure,  definition  of,  17 

urinary  secretion  and,  293,296 
range  of,  40 
significance  of,  134 
waves,  conduction  of,  128 
Pulsus  alternans,  blood-pressure  in,  250 

paradoxus,  197,  256 
Purgation,  blood-pressiu-e  and,  314 


R 


Radio-active     substances    effect    on 

blood-pressure,  333 
Raynaud's  disease,  270 
Reflex,  ocular,  436 

Renal   circulation,    hypertension   and, 
292 
colic  in  vascular  crises,  269 
function,  blood  flow  and,  292 

hypertension  and,  292 
symptoms  in  arterial  hypertension, 
278 
Respiration,  blood-pressure  and,  40 
Cheyne-Stokes,  blood-pressure  in, 

300 
venous  pressure  and,  149 
Retinal  arteries,  l)lood-pressure  in,  425 
pulsation  of,  434 
spasm  of,  433 
hemorrhages,  blood-pressure  in,  432 
Rheumatoid  arthritis,  hypotension  in, 

201 
Rib,     cervical,  producing    subclavian 

aneurysm,  246 
Riva-Rocci   type  of  sphygmomanom- 
eter, 65 
Rubino's   ocular   sphygmomanometer, 
425 


S 


Sahli's  sphygmobolometer,  186 
Salvarsan,  blood-pressure  and,  354 
Scarlet  fever,  blood-pressure  in,  214 
Hchiotz's  tonometer,  428 
Schott's  test  by  venous  pressure,  163 


446 


INDEX 


Sciatica,  hypotension  in,  201 
Scurvy,  371 

Secretion,  blood-pressure  and,  49 
Senility,  blood-pressure  in,  260 
Shock,  blood-pressure  in,  219,  396 

medical  or  toxic,  219  , 

Significance  of  blood-pressure  changes, 

133 
Silbermann's  sphygmomanometer,  101 
Singer's  sphygmomanometer,  96 
Sleep,  blood-pressure  and,  53,  315 
Smallpox,  blood-pressure  in,  215 
Sodium  chloride,  edema  and,  296 

metabolism,  blood-pressure 
and,  296 

nitrite,  blood-pressure  and,  350 
Spasm  of  retinal  arteries,  433 
Sphygmobolometer,  184 
Sphygmogram,  absolute,  in  blood- 
pressure,  164 
Sphygmomanometer,  aneroid,  112 
standardization  of,  119 

classification  of,  139 

compressed-air,  85 

Bendick's,  86 

Ring's,  108 

Bishop's,  82 

Bouloumie's,  123 

Brugsch's,  102 

Bussenius's,  107 

Erianger's,  96 

Faught's,  78 

Fleischer's,  105 

Francois  Frank's,  123 

Gartner's,  80 

Gibson's,  93 

Hertz's,  85 

HiU's,  77 

Janeway's,  76 

McKesson's,  423 

Mercer's,  76 

Muenzer's,  103 

Nicholson's,  74 

ocular,  Bajardi's,  426 
Rubino's,  425 

Oliver's,  85 

Pachon's,  112 

Potain's,  122 

Riva-Rocci  type  of,  65 

Silbermann's,  101 
Spjiygmomanometer,  Singer's,  96 

Stanton's,  66 

Tycos,  116 

Uskoff's,  98 

Van  Westenrijk's,  82 

Vaquez's,  112 

von  Recklinghausen's,  119 

Widmer's,  112 

Wybauw's,  108 
.  Sphygmomanometers,  comparative 

values  of,  124 
Sphygmoscope,  Pal's,  108 
Sphygmotonograph,  Jacquet's,  92 


Spinal  anesthesia,  blood-pressure  in,  412 
Standardization  of  aneroid  sphygmo- 
manometer, 119 
Stanton's  sphygmomanometer,  66 
Stasis,  high-pressure,  241,  277,  326,  340 

digitalis  in,  340 
Status  lymphaticus,  blood-pressure  in, 
371 
hypotension  in,  201 
Stephenson's  tonometer,  428 
Stewart's    method    of    estimation    of 

blood  flow,  170 
Strophanthus,  blood-pressure  effect  of, 

353 
Strychnin,  blood-pressure  effect  of,  355 
Subjective    method    of   estimation    of 

blood-pressure,  123 
Suckling,  effect  of,  on  blood-pressure, 

378 
Suprarenal  glands,  physiology,  35,  290, 

342 
Surgery,  blood-pressure  in,  394 
Surgical  hemorrhage,  blood-pressure  in, 
400 
shock,  blood-pressure  in,  396 
treatment  of,  401 
Syphilis,  blood-pressure  in,  222 
Syphilitic   aortitis,    blood-pressure   in, 

222,  298 
Syringomyelia,  blood-pressure  in,  393 
Systole,  time  relations  of,  25 
Systolic  blood-pressure,  39 
output,  27,  134 
pressure,  definition  of,  17 
estimation  of,  65 


Tabes  dorsalis,  392 
Tache  c6r6brale,  271 
Tachograph    in   estimation    of    blood 
flow,  180 
von  Kries,  180 
Tachycardia,  blood-pressure  in,  250 
Terminal  hypotension,  240 
Testes,  effect  of,  on  blood-pressure,  419 
Thoracentesis,  effect  of,  on  blood-press- 
ure, 405 
Thoracic  viscera,  manipulations  of,  and 

blood-pressure,  405 
Thyroid  extract,   blood-pressure   and, 

355 
Tigerstedt's  formula  of  blood-pressure 

quotient,  166 
Tissue  extracts,  blood-pressure  and,  366 
Tobacco  poisoning,  blood-pressure  in, 

235 
Tonometer,  Gartner's,  80 
Schiotz's,  428 
Stephenson's,  428 
von  Recklinghausen's,  119 
Tonus,  arterial,  estimation  of,  182 


INDEX 


447 


Toxemia,  alimentary,  365 

Training,  effect  of,  on  blood-pressure, 

385 
Traube-Herring  waves,  43 
Traube's  sign  in  aortic  insufficiency,245 
Tropical  climates,  blood-i^ressure  and, 

375 
Tuberculosis,  blood-pressure  in,  223, 

of  kidney,  283 
Tuberculous  meningitis,  blood-pressure 

in,  210 
Tumors  of  brain,  blood-pressure  in,  389 
Tycos  sphygmomanometer,  116 
Tympanites  in  vascular  crises,  268 
Typhoid  fever,  blood-pressure  in,  215 
inoculation,     low     blood-pressure 
after,  217 
Tyramin,  blood-pressure  effect  of,  203 


Uranium  nephritis,  blood-pressure  in, 

295 
Uremia,  blood-pressure  in,  298 
lumbar  puncture  in,  313 
venesection  in,  313 
Urethane,  blood-pressure  and,  356 
Urine,  secretion  of,  blood-pressure  and, 
296 
in  hypertension,  293 
Urticaria,  vascular  crises  and,  270 
Uskoff's  sphygmomanometer,  98 


Van   Westenrijk's   sphygmomanom- 
eter, 82 
Van  Zwaluwenbvu-g's  method  of  estima- 
tion of  blood  flow,  177 
Vaquez's  sphygmomanometer,  112 
Vascular  crises,  264 

angina  abdominalis  in,  267 
pectoris  in,  265 

angioneurotic  edema  and,  271 

apoplexy  in,  270 

biliary  colic  in,  269 

cerebral,  269 

chilblains  and,  271 

in  children,  271 

compensation,  280 

dermographism  and,  271 

epilepsy  and,  269,  388 

intermittent  claudication  in, 
270 

in  locomotor  ataxia,  392 

peripheral,  270 

renal  colic  in,  269 

treatment  of,  273 

tjTTipanites  in,  268 

urticaria  and,  271 

vasoconstriction  and,  265 


Vascular  crises,  vertigo  in,  269 

reactions  in  arteriosclerosis,  261 
tonus,  estimation  of,  182 
tree,  blood-pressure  throughout,  23 
Vasoconstriction,  vascular  crises  and, 

265 
Vasoconstrictor  system,  physiology  of, 

32 
Vasodilator  nerves,  physiology  of,  34 
system,  physiology  of,  34 
therapeusis,  220 
Vasomotor  centre,  effect  of  drugs  upon, 
220,  359 
efficiency  test,  152 
system,  physiology  of,  31 
Vasotonin,  blood-pressure  and,  356 
Veins,  physiology  of,  30 
Venesection,  effect  on  blood-pressure, 
327,  394 
in  uremia,  313 
Venous  blood-pressure,  23,  27,  140 
cardiac  action  and,  149 
critical,  26 

effect  of  drugs  on,  358 
effects  of  alterations  of  blood- 
pressure  on,  58 
estimation  of  blood  flow,  sys- 
tolic output  by,  171 
Frank  and  Reh's  method, 

142 
Frey's  method,  141 
Gartner's  method,  140 
Hooker  and  Eyster's 

method,  142 
Howell's  method,  142 
intravenous     needle     of 
Moritz  and  Tabora  in, 
143 
spring  manometers  in,  140 
factors  influencing,  146 
in  infectious  diseases,  207 
intra-ocular  pressure  and,  427 
intravenous     injection     and, 

150 
in  nephritis,  295 
respiration  and,  149 
Schott's  test  of,  163 
Veratrum  viride,  356,  398 
Vertigo  in  vascular  crises,  269 
Visceral  manipulations  and  blood-press- 
ure, 404 
Viscosity  of  blood,  37 

in  pregnancy,  309 
and  hypertension,  308 
Visual  accommodation,  blood-pressure  - 
and,  435 
method   of  estimation   of   blood- 
pressure,  108 
Vries-Reilingh's  method  of  estimation 

of  arterial  tonus,  182 
Von  Kries's  tachograph,  180 
Von  Recklinghausen's  formula  of  blood- 
pressure  quotient,  168 


448 


INDEX 


Von  Recklinghausen's  sphygmomano 

meter,  119 
Vomiting,  blood-pressure  during,  341, 
390 
dangers  of,  341 

of  pregnancy  and  blood-pressure, 
420 

W 

White  line  of  adrenal  insufficiency,  271 
Widmer's  sphygmomanometer,  112 


X-RAY    radiation    over    the    adrenal 
glands,  334 


YoHiMuiN,  blood-pressure  effect  of,  357 


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PRINTED  IN  U.S.*.              CAT.    NO.    24    161                S8 

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A  001367  267  o 


WB280 
N855t 
1917 
Norris,  George  William 
Blood-pressure, . . 


WB280 
N855b 

1917 
Norris,  George  William 
Blood-pressure, . . 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

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